EMPLOYEE FORMS

FORM NO. NAME
EE-10         OptiMed Enrollment Form - Late Entrant
EE-20         ACH Premium Authorization Agreement
EE-30         United Group Programs Enrollment & Change Form (Form 1B)
EE-40         Affidavit of Domestic Partnership Form
EE-50         Declaration of OptiMed Termination of Domestic Partnership Form
EE-60         Cafeteria/ Section 125 Flexible Spending Account Enrollment Form
EE-65         Cafeteria/ Section 125 Flexible Spending Account Claim Form
EE-70         Credit Card Authorization Form - Premium Payment
EE-80         Claim Form for OptiMed
EE-90         GAP Claim Form
EE-100       Catalyst Rx Direct Member Reimbursement Form
EE-110       Dental Claim Form
EE-120       Avesis Vision Benefits Claim Form
EE-130       Change in Status Election Form – Premium Only
EE-140       Change in Status Election Form – Cafeteria

EMPLOYER FORMS/NOTICES

FORM NO. NAME
ER-10         Authorization Agreement for a One Time/Recurring ACH Premium Withdrawal
ER-20         MEC Signature/Banking Information Form
ER-30         Credit Card Authorization Form - Premium Payment
ER-40         Authorization Agreement for Recurring ACH Claim Check Runs Withdrawals

NOTICE1  ACA Fully Insured Plans
NOTICE2  ACA Self-Insured Plans

AGENTS / BROKERS FORMS

FORM NO. NAME
AG-10          Authorization Agreement for Direct Deposit of Commissions
AG-20          Request for Proposal Form
AG-30          Agent Commission Agreement
AG-40          Agent Commission Schedule
AG-50          UGP Agent Agreement
AG-60          Agent Data Sheet
AG-70          W-9
AG-80          Signature Collection Form
AG-90          Agents Appointment Fee