Ready to Enroll?
Submit the following items to your Broker or Sales Representative to enroll your group.
|Proof of Payroll (NYS-45) for the most recent quarter||Required for new groups. Notations should be based on the employer's eligibility guidelines. Employees working fewer than 20 hours per week cannot be eligible.||Each employee appearing on the NYS-45 must be noted to indicate eligible, ineligible, or terminated.
If no NYS-45 is available, a payroll register may be accepted.
If no payroll register is available, W-4 forms may be accepted.
|Tax Documentation for the most recent filing||Required for new groups.||Single owner: Schedule C or Schedule F.
Partnership: 1065 with 105 K-1 forms for all partners.
Corporation: 1120 including section(s) detailing shareholder information.
Subchapter S Corporation: 1120S with 1120S K-1 forms for all shareholders.
Charitable organizations: IRS Form 990. If exempt from filing tax returns with the IRS, a copy of the exemption is required.
Start-up company that has been operating for less than one year: Business Certificate, DBA Certificate, Partnership Certificate, Certificate of Incorporation, Certificate of Authority, receipt of Federal Tax ID Number, or similar tax documentation verifying the business is authentic.
|New Business Group Information Form - Provides basic enrollment information and federal and state regulatory information needed for the company. An instructional aid has been provided for assistance.
Eligibility Policy for New Employees - Establishes the company's standard coverage waiting periods for 'new hires' and 'rehires.'
Attestation Form - Identifies newly hired employees, owners, partners or retirees not listed on the NYS45-ATT, and sole proprietors.
|Completed and signed by the employer representative.|
|Group Contract, Benefit Summary & Rate Sheet||This document, provided by the Sales Representative, identifies the specific plan(s) you are enrolling in and the premium/rate(s).||Signed by the employer representative. Be sure to return all pages.|
|Handicapped Dependent Application Form (if applicable)||Handicapped dependents who met certain qualifications may be eligible for continued coverage.||Completed and signed by both the subscriber and the member's attending physician.|
|Medicare Eligibility Form (if applicable)||Identifies members in the group who are eligible for Medicare and reason for eligibility.||Completed and signed by the group representative and member.|
|First Month's Premium||Required for new groups.||Provide a check issued on the business account.|
|Member Application Forms||Provides information about the employee and his/her eligible family members for enrollment in medical, dental coverage or Medicare coverage.||Completed and signed by the subscriber, with the group number and employer name filled out by the employer representative.|
|Waivers of Group Coverage||Required for new groups.||Must be completed by all eligible employees that are not electing coverage.|