Ready to Enroll?

Submit the following items to your Broker or Sales Representative to enroll your group.

Requirements Purpose Action Needed
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.

Commercial Underwriting Package 

Group Information Form Instructions

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.
The following items must be submitted after you have enrolled in coverage.
Forms Purpose Action Needed
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.
Please review the following policies and guidelines.
Documents Purpose Action Needed
Medical Commercial Underwriting Guidelines
Dental Underwriting Overview
Summarizes the Health Plans guidelines and eligibility requirements for group coverage. Adherence to the guidelines.