Form Name | Effective Date | Download Form |
---|---|---|
New Group Submission |
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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 |
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Group Level Change Form |
01/01/2020 | Download |
Administration |
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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 |
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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 |
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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. |
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Steps to Find Benefit Summaries in Your Humana Quote |
01/01/2020 | Summary | |
Dental HMO Benefit Summaries |
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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 |
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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 |
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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 |
01/01/2020 | Download |
Provider Search Instructions Dental PPO |
01/01/2020 | Download |
Vision |
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Vision Coverage Flyer |
01/01/2020 | Download |
Vision Provider Search Instructions |
01/01/2020 | Download |