New Group Paperwork

Required

New Group ApplicationOpen a PDF
- InstructionsOpen a PDF
- New Group ChecklistOpen a PDF
Signed rate sheets and benefit selections
Enrollment Forms
NYS-45 or other state equivalents from the most recently filed report
For a new employee, a current payroll report and W-4’s

Healthy NY New Group ApplicationOpen a PDF
- Healthy NY New Group ChecklistOpen a PDF
- Healthy NY Eligibility Policy FormOpen a PDF
Signed rate sheets and benefit selections
Enrollment Forms
NYS-45 or other state equivalents from the most recently filed report
For a new employee, a current payroll report and W-4’s

Business Tax Filings if three or fewer enrolling or enrolling owner is not on NYS-45
SS-4 Letter and Operating Agreement or Articles of Organization/ Incorporation for a startup company
(50 or more full-time equivalent employees) 1094-C to be submitted if the group is part of an applicable large employer
Waiver of Group Coverage for employees who decline enrollmentOpen a PDF
Dependent Certification (Student Verification) FormOpen a PDF
Adult Disabled Dependent FormOpen a PDF
Dependent Age 29 FormOpen a PDF
Administrator Electronic and Web Enrollment AgreementOpen a PDF