Forms
Please see your account manager or broker if the form you need is not listed
Employer Access for Web Enrollment & Updates
Group Underwriting Forms
- New Group Paperwork
- Renewal Group Paperwork
- Healthy New York RecertificationOpen a PDF
- Healthy NY Eligibility Policy FormOpen a PDF
Prescription Claims Forms
Claims Forms
- $300 ActiveRewards Reimbursement Claim FormOpen a PDF
- $300 Univera Fit Dollars Reimbursement FormOpen a PDF
- Dental Claim FormOpen a PDF
- Medical Claim FormOpen a PDF
- Active&Fit ExerciseRewardsOpen a PDF
- Dental RewardsOpen a PDF
Eligibility Certification Forms
- Continuing Coverage for Students on Medical Leave FormOpen a PDF
- Dependent Certification FormOpen a PDF
- Adult Disabled Dependent FormOpen a PDF
- Domestic Partner Affidavit FormOpen a PDF
- Qualified Medical Child Support Order Certification FormOpen a PDF
- Qualified Medical Child Support Order Disenrollment FormOpen a PDF
- Young Adult Option Certification FormOpen a PDF
- ARPA COBRA Subsidy Attestation FormOpen a PDF
- Medicare Eligibility Form for Commercial PlansOpen a PDF
Medical & Dental Enrollment Forms for Groups with 101 or more full-time Equivalent Employees
Forms for Small Groups (100 or fewer), Individuals, and Families are available in Univera on Demand
- Choose application based on whether the product requires a primary care physician
- Select the plans your group offers from the dropdown(s) under Medical and Dental Plan Selection
- PPO/EPO/Indemnity - No Primary Care Physician (PCP)Open a PDF
- POS/HMO - Requires Primary Care Physician (PCP)Open a PDF
Additional Enrollment Forms
- Additional Dependent AddendumOpen a PDF
- Membership Cancellation Worksheet Open a PDF
- Vision Enrollment FormOpen a PDF
Medicare Enrollment Forms
- Medicare SupplementOpen a PDF
- Simply Prescriptions DisenrollmentOpen a PDF
- Medicare PPO / SeniorChoice HMO-POS DisenrollmentOpen a PDF
