Employer Forms



Dental Master Applications

Employer Dental PPO & Vision Master Application

PDF

   

Employer Dental PPO & Vision Master Application
Arizona & Nevada

PDF

   

Employer Dental PPO & Vision Master Application
California

PDF

   

Employer Dental PPO & Vision Master Application
Texas

PDF

   

Employer Topaz Dental PPO and Vision Master Application
Utah

PDF

   

Employer Dental IndemnityPlus & Vision Master Application

PDF

   

Employer Dental IndemnityPlus & Vision Master Application
Arizona & Nevada

PDF

   

Employer Dental IndemnityPlus & Vision Master Application
California

PDF

   

Employer Topaz Dental IndemnityPlus & Vision Master Application
Utah

PDF

   

Dental Employee Forms

Employee Dental Enrollment & Change Form

PDF English

PDF Spanish

Online


Employee Dental Enrollment & Change Form
California

PDF English

PDF Spanish

Online


Employee Coverage Termination Form

PDF

Online

 




Vision Master Applications

Employer Access Vision Master Application

PDF

   

Employer Vision PPO Master Application (EyeMed)

PDF

   

Vision Employee Forms

Employee Vision Enrollment & Change Form

PDF English

PDF Spanish

Online


Employee Coverage Termination Form

PDF

Online

 




Dental & Vision Forms

Employee Dental PPO & Vision Enrollment Form

PDF

PDF Spanish

Online


Employee Coverage Termination Form

PDF

Online

 





Life Master Applications

Employer Gold, Silver & Bronze Life Master Application

PDF

   

Employer Gold, Silver & Bronze Life Master Application
Texas

PDF

   

Employer Essential Life Master Application

PDF

   

Employee Group Term Life Roster

PDF

   

Life Employee Forms

Employee Enrollment Form
Essential Life & Flex Life

PDF

   

Employee Enrollment Form
Gold, Silver & Bronze Life

PDF

   

Employee Change of Beneficiary Form

PDF

   

Employee Coverage Termination Form

PDF

Online

 




Short Term Disability Master Application

Employer Short Term Disability Master Application

PDF

   

Short Term Disability Employee Forms

Employee Short Term Disability Enrollment Form

PDF

   

Employee Short Term Disability Enrollment Form
Kentucky

PDF

   

Short Term Disability Enrollment Roster Template

PDF

   

Employee Standard Health Form
Illinois

PDF

   

Employee Waiver of Coverage Form

PDF

   

Employee Coverage Termination Form

PDF

Online

 





Other Forms

Check by Fax Form

PDF

   

COBRA Form

PDF

   

Continuation of Coverage for Disabled Dependent Form

PDF

   

HIPAA Business Associate Agreement

PDF

   

HIPAA Notice

PDF English

PDF Spanish

 

Language Assistance Program Notice

PDF

   

Census Enrollment Template

PDF