| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
Humana New Group Enrollment Checklist |
01/01/2020 | Download |
|
Employer Application-all lines except DHMO |
01/01/2020 | Download |
|
Employer Application-DHMO |
01/01/2020 | Download |
|
ACH Authorization Form |
01/01/2020 | Download |
|
In Force Group Forms |
||
|
Group Level Change Form |
01/01/2024 | Download |
|
Administration |
||
|
Online Benefits Administration Guide |
01/01/2020 | Download |
|
Employer Guide - Dental (up to 99 employees) |
01/01/2020 | Download |
|
Employer Guide - Vision (up to 99 employees) |
01/01/2020 | Download |
|
Employer Guide - Life (up to 99 employees) |
01/01/2020 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Application-all lines except DHMO |
01/01/2020 | Download |
|
Employee Application Small Group-DHMO |
01/01/2020 | Download |
|
Employee Application Large Group 101+-all lines except DHMO |
01/01/2020 | Download |
|
Employee Application Large Group 101+-DHMO |
01/01/2020 | Download |
|
Employee Change Form |
01/01/2020 | Download |
|
Employee Evidence of Health (for life coverage over guarantee issue amount) |
08/01/2022 | Download |
|
Life Authorization Form (for life coverage over guarantee issue amount) |
01/01/2020 | Download |
|
Claim Forms |
||
|
HIPAA Form |
01/01/2020 | Download |
|
Dental Claim Form |
01/01/2020 | Download |
|
Vision Claim Form (for out of network reimbursement) |
01/01/2020 | Download |
|
Life Claim Form |
01/01/2020 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
Dental PPO, Vision and Life plan summaries are generated specific for each group and available to download from the Humana quote. Contact your RBG Team with questions. |
|||
|
Steps to Find Benefit Summaries in Your Humana Quote |
01/01/2020 | Summary | |
|
Dental HMO Benefit Summaries |
|||
|
LS100 Plan Summary |
01/01/2020 | Summary | |
|
LS200 Plan Summary |
01/01/2020 | Summary | |
|
LS300 Plan Summary |
01/01/2020 | Summary |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
2020 Specialty Producer Guide - Groups 1 to 100 |
01/01/2020 | Download |
|
2020 Standalone Go365 Rate Card - Groups of 100 to 999 |
01/01/2020 | Download |
|
Humana Plans Brochure |
01/01/2020 | Download |
|
Bundling Discount Flyer |
01/01/2020 | Download |
|
Jet Dental Information Flyer |
09/01/2021 | Download |
|
Jet Dental Marketing Flyer |
12/01/2021 | Download |
|
Lifestyle Discount Program Value Adds for Members |
01/01/2020 | Download |
|
MyHumana Website Flyer |
06/01/2023 | Download |
|
Products Available by State Flyer |
01/01/2022 | Download |
|
Dental |
||
|
Dental Enhanced Preventive Care |
01/01/2020 | Download |
|
Dental Extended Annual Maximum |
01/01/2020 | Download |
|
Dental Unlimited Annual Maximum |
01/01/2020 | Download |
|
Dental PPO Network Flyer |
01/01/2020 | Download |
|
Provider Search Instructions Dental HMO or Dental PPO |
02/01/2025 | Download |
|
Vision |
||
|
Vision Coverage Flyer |
01/01/2020 | Download |
|
Vision Provider Search Instructions |
01/01/2020 | Download |
