Large Group Forms

(51+ total employees)

Certification of Domestic Partnership

Combined Employer Form Health Questionnaire & Employer Group Application for HMO and POS coverage

Disclosure Form

Group Electronic Funds Transfer Authorization/Change Form

Group Enrollment/Change Form for prospective groups of 51+ employees & for current groups

Health Questionnaire long form

Health Questionnaire short form

Wage & Tax Form

Waiver Form

Disclosure Auth Form

New Large Group Checklist
  • Employer Form
  • Employer Group Application
  • Disclosure Form
  • Enrollment form from each full-time employee applying (If employee is applying, but waiving spouse or dependent children, please submit an enrollment form and waiver)
  • Waiver from each full-time employee waiving coverage
  • Most recent wage & tax
  • Prior carrier bill
  • Check for 1 month's premium

Group must be complete and ready to submit to underwriting by the 10thof the month prior to the effective date.

Large Group Quote Checklist