See Specific Forms
New Business Submission Checklist
Anthem Employee Enrollment Form 1.24
Anthem Employer Application - All Lines 1.24
Electronic Funds Transfer Authorization - Initial & Recurring Payment Options
Proprietor/Partner/Corporate Officer Eligibility Statement
Conditions of Enrollment Start Up Companies PEO Spin Offs
PEO Employer Authorization
See Specific Forms
New Group Submission Checklist 1.24
Blue Shield Employee Enrollment Form 7.24 Effective Dates
Blue Shield Employee Enrollment Form 1.24 Effective Dates
Refusal of Coverage Form Effective 12.23
Blue Shield Employer Application 7.24 Effective Dates
Blue Shield Employer Application 1.24 Effective Dates
Small Business Owner Eligibility Statement
Small Group Initial Payment Form
Start-up Spin-off Companies Small Business Eligibility Statement
See Specific Forms
Submission Checklist
CalCPA Health Employee Enrollment & Change Form
CalCPA Health Employer Subscription Agreement
Medicare Secondary Payer Exception Form (for groups <20 employees)
HealthEquity HSA Administration Member Enrollment
HealthEquity HSA Beneficiary Designation Form
HealthEquity HSA Administration Employer Enrollment
COBRA Administration Authorization
See Specific Forms
CalChoice Submission Checklist 7.22
CalChoice Employee Enrollment Form 4.24 Effective Dates
CalChoice Employer Application 6.24 Effective Dates
CalChoice Employer Application 1.24 Effective Dates
ACH Payment Form 7/24
Case Submission Acknowledgement (for groups submitted after the requested effective date)
Common Ownership Statement
Group Size Attestation
Owner Partner Statement Form
Prior Carrier Cancellation Letter Template
See Specific Forms
See Specific Forms
See Specific Forms
Universal Enrollment/Change Form
Contact your RBG representative for a customized employee application or use the Universal Enrollment/Change Form
Beneficiary Designation Form
Guard Anytime Pre-Registration and Consent of Electronic Materials
Guard-O-Matic Form ACH
Contact your RBG representative for an employer application
See Specific Forms
Humana New Business Checklist
Employer Application-all lines except DHMO
Employer Application-DHMO
Employee Application Small Group-all lines except DHMO
Employee Application Small Group-DHMO
Employee Application Large Group 101+-all lines except DHMO
Employee Application Large Group 101+-DHMO
ACH Authorization Form
See Specific Forms
New Business Submission Checklist - Group Size 2-19 & Virgin Groups
New Business Submission Checklist - Group Size 20+
RHABT Employee Application Group Size 2-19
RHABT Employee Application Group Size 20-99
RHABT Employer Application
RHABT Participation Agreement
Product and Benefit Selection Form
Participation Certification Form
Direct Debit Authorization Form
See Specific Forms
New Business Checklist - Small Group 4.24
Employee Application - Small Group 4.24
Employer Application - Small Group 1.24
Premium Payment Options
Sole Proprietor, Partner or Corporate Officer Eligibility Statement
New Employee Verification Form
New Business Checklist - Large Group 1.24
Employee Application - Large Group 1.24
Employer Application - Large Group 1.24
Declination of Coverage Form
See Specific Forms
New Business Checklist
Employee Application
Employee Application - Standalone Dental & Vision
Employee Application - Life and DI
Employer Application for Small Business
Employer Application for Standalone Dental & Vision
Product and Benefit Selection Form 1.24
Direct Debit Authorization Form
Participation & Floor Certification (for groups situs in California)
See Specific Forms
See Specific Forms