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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 ACH Premium Withdrawal
ER-20 Authorization Agreement for Recurring ACH Premium Withdrawals
ER-30 MEC Signature/Banking Information Form
ER-40 Credit Card Authorization Form - Premium Payment
ER-50 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