BDI Census
– Use for group insurance quotes for groups of 15 or less
473k
BDI Long Census – Use for group insurance
quotes for groups of 16-50
701k
BDI PEO Quote
– For quotes for PEO/employee leasing services
245k
Aetna Forms
file
size
Aetna Large Group Employee Enrollment & Change
Form –
Use for groups of 50 or more
270k
Aetna Small Group Enrollment & Change
Form –
Use for groups of less than 50
62k
Aetna Third Party Authorization
Form –
Allows individual or company to have access to personal
health information for assistance with claims.
30k
Aetna Rx Home Delivery Form
415k
Aetna Medical Claim Form
312k
Aetna Dental Claim Form
170k
Aetna Prescription Drug Claim Form
358k
AvMed
file
size
AvMed
Employee Application
166k
Blue
Cross/Blue Shield of Florida
file
size
BC/BS
Employee Enrollment Form
348k
BC/BS Change Form
68k
BC/BS
Authorization for release of personal health information
87k
BC/BS Mail Order Prescription Form
103k
BC/BS PPO Claim Form
487k
BC/BS Dental Claim Form
96k
BC/BS Prescription Claim Form
106k
United
Healthcare
file
size
United
Healthcare Large Group Employee Enrollment Form –
Use for groups of 50 or more
47k
United Healthcare Small Group Employee
Enrollment Form –
Use for groups of less than 50
28k
United
Healthcare HIPAA Disclosure Authorization Form –
Allows individual or company to have access to personal health
information for assistance with claims.
87k
United Healthcare Mail Order Prescription
Form
46k
United Healthcare Health Insurance
Claim Form
22k
United Healthcare Dental Claim Form
286k
United Healthcare Prescription Drug
Reimbursement Form
52k
KMG
America/Kanawha
file
size
Employee Voluntary
Worksite Application –
For all voluntary coverage types: Life, Cancer, Disability
94k
Life Claim Form
17k
Cash Cancer
Plus Claim Form
107k
Disability/Income Protector Claim Form
168k
*Note:
To terminate employees from coverage under KMG, there is no
separate form; just cross through the name on the invoice and
mark it with a “T” before returning it to KMG.
Ameritas
Dental
file
size
Ameritas Group
Dental Application –
Use for both Wisdom and Pearl Series
92k
Ameritas Pearl Request for Service –
Use to change coverage/add/terminate employees and dependents
on a Pearl Series plan
194k
Ameritas Wisdom
Request for Service –
Use to change coverage/add/terminate employees and dependents
on a Wisdom Series plan
Downloadable
Forms
