Micro Group Forms

• Micro Group Request for Proposal (PDF)
• Micro Group Employer Documentation (PDF)

Community Group (2-50) Group Master Application (Effective Date of 03/09 and beyond)

• Group Master Application (2-50)

Community Group (2-50) General Forms

• Employee Enrollment & Change Form (PDF)
  • English Version
• Delayed Enrollment Exception Request
• Request for Proposal (PDF)
• Affidavit of Qualifying Domestic Partnership (PDF)
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Waiver
  • English Version (PDF)
• Newborn Application (PDF)
• Employee Cancellation Form (PDF)
• Selections Basic Employee Cancellation Form (PDF)
• Group Size Certification (PDF)

Notices & Disclosures

• Annual Notification (2-50) (PDF)
• Dental Privacy Practices (PDF)
• Pre-Sale Disclosure (PDF)
• Post-Sale Disclosure (PDF)

Groups of 51+ Employees

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

• Group Master Application
• Benefit Selection Insert 100+

Merit & Experience Group (51+) General Forms

• Employee Enrollment & Change Form (PDF)
  • English Version
• Delayed Enrollment Exception Request
• Request for Proposal (PDF)
• Affidavit of Qualifying Domestic Partnership (PDF)
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Waiver
  • English Version (PDF)
• Newborn Application (PDF)
• Employee Cancellation Form (PDF)
• Selections Basic Employee Cancellation Form (PDF)

Notices & Disclosures

• Annual Notification
• Annual Notification (51+) (PDF)
• Annual Notificiation (No Wait) (PDF)
• Dental Privacy Practices (PDF)
• Pre-Sale Disclosure (PDF)
• Post-Sale Disclosure (PDF)

Individual Plans

• Agent Change Request - Change the agent of record for a health coverage plan
• Application for Individual Coverage (PDF)
• Application for Individual Coverage (Spanish) / Solicitud de Cobertura Individual (PDF)
• Application for DentalOne (PDF)
• Pre-Sale Disclosure List for Individual Plan Members (PDF)
• Newborn Application (PDF)
• Standard Health Questionnaire (PDF)
• Electronic Funds Transfer (PDF)

Medicare Plans

Agent Change Request - Change the agent of record for a health coverage plan

Regence MedAdvantage + Rx Enhanced (PPO), Regence MedAdvantage + Rx Classic (PPO) and Regence MedAdvantage (PPO)

• Enrollment Form
• 2009 (PDF)
• 2010

• Short Enrollment Form (for members upgrading their plan)
  All pages of this form must be given to inquiring or applying individuals.
• 2009 (PDF)
• 2010

• Medicare Supplement Application
• EFT (Electronic Funds Transfer form)

Medicare Script (PDP)

• Enrollment Form
• 2009 (PDF)
• 2010
• Short Enrollment Form (for members upgrading their plan)
  All pages of this form must be given to inquiring or applying individuals.
• 2009 (PDF)
• 2010