Individuals & Families

• Individual & Family Plan Application (PDF)
• Transfer of Funds for Monthly Premium Payment (PDF)

Small Groups

• 2009 Group Employer Application (PDF)
  For business effective Jan. 1, 2009 and after.
• 2010 Group Employer Application (PDF)
  For business effective Jan. 1, 2010 and after.
• Employee Enrollment (PDF)
• Quote Request (PDF)
• Underwriting Guidelines (PDF)
• Waiver of Health Insurance Coverage (PDF)

Medium & Large Groups

• Employee Enrollment (PDF)
• Group Master Application (PDF)
• Quote Request (PDF)

Medicare Advantage

• 2009 Clear Care Plan Election Form (PDF)
• Clear Care HMO Election Form 2010 (PDF)
• Clear Care PPO Election Form 2010 (PDF)
• Clear Care Sound Prequalification Form (PDF)
• Transfer of Funds for Monthly Dues Payment (PDF)

HealthPays HSAs

• Bank of America HSA Employer Group Set-Up Form (PDF)

Other Forms

• Benefit and Prescription Claim (PDF)
• Disclosure Document (PDF)
• Mail-Order Pharmacy Transfer Form (PDF)
• Physician Selection/Change Form (PDF)