Renewal Group Paperwork
Required
Commercial
- Annual Group Information Form
- Signed rate sheets and benefit selections
- Enrollment Forms
Healthy NY
Medicare
- Signed Rate Sheet
- Enrollment Applications
- Medicare Eligibility FormOpen a PDF
If Applicable
- Supplemental Address FormOpen a PDF
- Healthy NY Eligibility Policy FormOpen a PDF
- 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
- Full Time Equivalent (FTE) Calculation FormOpen a PDF
Additional Documents
Required
Commercial
- Annual Group Information Form
- Signed rate sheets and benefit selections
- Enrollment Applications
Medicare
- Signed Rate Sheet
- Enrollment Applications
- Medicare Eligibility Form
If Applicable
- FSA Administrator (LBS or other TPA)
- STM Grids for Custom Products
- Eligibility Policy for New EmployeesOpen a PDF
- Supplemental Address FormOpen a PDF
- COBRA Administrative Agreement
- Dependent Certification (Student Verification) FormOpen a PDF
- Adult Disabled Dependent FormOpen a PDF
- Dependent Age 29 FormOpen a PDF
- Full Time Equivalent (FTE) Calculation FormOpen a PDF
