New Group Paperwork
Required paperwork
Commercial
Healthy NY
Medicare
- Medicare Group Information FormOpen a PDF
- Signed rate sheet
- Enrollment applications
- Medicare Eligibility FormOpen a PDF
If applicable
- 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
- Community Rated Subgroup ApplicationOpen a PDF
Additional documents
Required paperwork
Commercial
- New Group ApplicationOpen a PDF
- Signed rate sheets and benefit selections
- Enrollment applications
- COBRA Administrative AgreementOpen a PDF
Medicare
- Medicare Group Information FormOpen a PDF
- Medicare signed rate sheet
- Medicare enrollment applications
- Medicare Eligibility FormOpen a PDF
If applicable
- Name of FSA Administrator
- Certificate of Coverage Run List (Previous Carrier)
- Stop Loss Paperwork
- STM Grids for New Products
- Dependent Certification (Student Verification) FormOpen a PDF
- Adult Disabled Dependent FormOpen a PDF
- Dependent Age 29 FormOpen a PDF
