Small Group Forms

(2-50 total employees)

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

Employee Census Form

Group Electronic Funds Transfer Authorization/Change Form

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

Small Employer Uniform Employee Application for Group Health Insurance Applying & Waiving

Small Employer Uniform Employee Application for Group Health Insurance - for prospective groups Word Document, complete online

Small Group Disclosure Forms

Wage & Tax Form

Disclosure Auth Form


New Small Group Checklist

  • Employer Form
  • Employer Group Application
  • Disclosure Forms
  • Uniform application from each full-time employee applying (If employee is applying, but waiving spouse or dependent children, sign page 4 of the application. If employee is waiving, fill out only pages 1-4)
  • 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 10th of the month prior to the effective date.