Employee Forms and Applications, including Enrollment Spreadsheet Tool (groups 1-100)

Form		Download
Enrollment Spreadsheet		2023 - Q1 \| Q3 2022 - Q1 \| Q2 \| Q3 \| Q4
Guide to Enrollment Spreadsheet		Download
Employee Application Employees should complete this form to enroll in a group medical plan, group vision plan, or group term life policy. For employee enrollments to a new or existing employer group. As a reminder, once a fillable PDF is saved to the desktop, you cannot go back and make changes.
	2023 Employee Application New/renewing groups effective July 1, 2023	English (Fillable PDF, 1.4 MB) Spanish (Fillable PDF, 1.6 MB)
	2023 Employee Application New/renewing groups effective January 1, 2023	English (Fillable PDF, 1.4 MB) Spanish (Fillable PDF, 1.6 MB)
	2022 Employee Application New/renewing groups effective October 1, 2022	English (Fillable PDF, 1.5 MB) Spanish (Fillable PDF, 876 KB)
	2022 Employee Application New/renewing groups effective January 1 through September 30, 2022	English (Fillable PDF, 1.23 MB) Spanish (Fillable PDF, 1.46 MB)
Subscriber Change Request Employees can change personal information, change plans during open enrollment, enroll new dependents, or cancel dependents (please include the Refusal or Cancellation of Personal Coverage form).
	2023 Subscriber Change Request New/renewing groups effective July 1, 2023	English (Fillable PDF, 1.3 MB) Spanish (Fillable PDF, 1.4 MB)
	2023 Subscriber Change Request New/renewing groups effective January 1, 2023	English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.4 MB)
	2022 Subscriber Change Request New/renewing groups effective October 1, 2022	English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.15 MB)
	2022 Subscriber Change Request New/renewing groups effective January 1 through September 30, 2022	English (Fillable PDF, 1.2 MB) Spanish (Fillable PDF, 1.15 MB)
Refusal of Coverage Employees complete this form if they, their spouse/domestic partner, or other dependents refuse their employer’s medical or dental plan coverage
	2023 Refusal of Coverage form New/renewing groups effective July 1, 2023	English (Fillable PDF, 765 KB) Spanish (Fillable PDF, 881 KB)
	2023 Refusal of Coverage form New/renewing groups effective January 1, 2023	English (Fillable PDF, 764 KB) Spanish (Fillable PDF, 880 KB)
	2022 Refusal of Coverage form New/renewing groups effective October 1, 2022	English (Fillable PDF, 756 KB) Spanish (Fillable PDF, 876 KB)
	2022 Refusal of Coverage form New/renewing groups effective January 1, 2022	English (Fillable PDF, 567 KB)
Continuity of Care program brochure		English Spanish Chinese Vietnamese Hindi Korean
Request for Continuity of Care Service for established members and new enrollees Members of HMO-only groups with qualifying conditions may be able to complete care with a non-network provider.		English Spanish Chinese Vietnamese Hindi Korean
Authorization for the use or disclosure of health information		English Spanish Chinese Vietnamese Hindi Korean
Declaration of Disability of Over-Age-Dependent Children For enrolled dependent children who normally lose their eligibility because of age but who have a physical or mental disabling injury.		English Spanish
Waiver of Premium Claim Form – Life If a member becomes totally disabled, the life premium may be waived.		Download
Premium Only Plan (POP) HealthEquity's POP lets employers cut payroll taxes without cutting payroll. If an employer requires employees to contribute to the cost of their insurance, a Section 125 POP allows them to do so with pre-tax dollars.		Download
CVS Mail Order Form		Download

Employee Forms and Applications, including Enrollment Spreadsheet Tool (groups 1-100)

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