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Broker Product Forms and Applications
Use the Right Forms
For EvolveSM, ActivateSM, InnovaSM, EngageSM, HSA Healthplan 2.0SM and Regence BridgeSM Medigap Plans business, use these new forms only. Do not use the forms listed below for these products.

Set up automatic deposits for your commission payments:
Authorization Agreement for Electronic Funds Transfer

Creditable Coverage Notice Forms

Important Note: 2012 Product Changes
Effective January 1, 2012, some Regence products will be discontinued or closed to groups sized 1-99. Please see the Product Transition Page for more information.

Groups of 2-50 Employees Groups of 51+ Employees Medicare Plans

Groups of 51+ Employees

Merit & Experience Group (51+) Group Master Application and Benefit Selection Insert (Effective Dates of 03/09 and beyond)

Merit & Experience Group (51+) General Forms

Notices & Disclosures


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