Login to Martin Support

2-50

• IMQ form
• Enrollment form

Individuals

• 2024 IHC App
• Davis Vision Reimbursement Claim Form
• HIPAA Authorization for Disclosure of Health Info

2-50

• Medical/Dental/Vision Enrollment/Change Form

2-50

• Enrollment form
• Master Application
• Eligibility Letter Template
• Enrollment Spreadsheet

2-50

• EOI form

Individuals

• 2025 IHC Application
• New IHC Enrollment Form
• 2023 IHC app for child only policy
• 2023 IHC Spanish enrollment form
• 2023 IHC Dental & Vision App- Spanish
• 2023 IHC Dental & Vision App
• IHC Termination Form
• Away from Home Care Services Application
• Spanish Version: Special Enrollment Documentation Requirements

51+

• Midsize/Large group enrollment form
• 51+ Master Application
• Spanish Version: Midsize Enrollment Form
• Horizon Large Group Certification

2-50

• 2023 SEH Master Application
• 2023 SHOP Master Application
• Level Select Master App
• HSA Funding Form
• HSA Setup Form
• Mellon Paperwork
• Declaration of Understanding
• Spanish Version: Waiver of Coverage
• Small Employer Common Ownership Certification
• Auto Pay Application
• Small Group Enrollment/ Change Request
• Small Employer Certification
• Small Employer Waiver
• 2-5 Form
• Away From Home Care Services Application
• Conversion Request Form

2-50 & 51+

• Disabled Dependent Form

Individuals, 2-50 & 51+

• Horizon General Claim Form

Individuals & 2-50

• Disabled Dependent Form

• Request To Represent a Deceased Member
• Deductible Carry Over Credit Report
• 51+ Employee Application

2-50

• AXA Member Enrollment Form
• AXA Member Enrollment Form w/Disability
• Davis Vision claim form
• Bundle New Business Paperwork *New USAble app eff. 10/1/21*
• Horizon Dental Waiver
• Small Employer Vision Group Application
• Small Employer Dental Group Application

Individuals

• IHC dental & vision app

2-50

• Domestic Partner form
• SOH form

Individuals

• Enrollment Change Form

• Statement of Responsibility
• Metlife Binder Check Cover Form
• Group Submission Disclosure Form
• eCensus Format

Individuals

• NABIP Consumer Consent Form
• CMS Model Consumer Consent Form

2-50 & 51+

• COBRA General Notice
• COBRA Model Election Notice

51+

• Enrollment Form

Individuals

• 2024 IHC Enrollment Form
• Payment Form for IHC
• Individual BOR template

2-50

• 2021 Master Application
• 2021 Employee Application
• 2021 Waiver
• 2021 Certification
• Small Group EFT form

2-50

• IMQ form
• Level Funded Enrollment Form
• 2024 OHI Master App
• 2024 OHP Master App
• HSA Certificate of Understanding
• 2023 Master Application
• EE Enrollment Form
• Group Contact/Address/Name Change Form
• Waiver
• 2021 Certification
• Oxford Verification Form
• Common Ownership Form for Affiliated Groups

51+

• 51+ EE Enrollment Form

Individuals, 2-50 & 51+

• Sweat Equity Program Reimbursement Form

Individuals

• Health Insurance Claim Form
• HIPAA Member Authorization
• Prescription Drug Reimbursement Claim Form
• OptumRx Authorization Form

2-50

• OBM Master Application
• UHC Dental & Vision Enrollment Application
• UHC Dental & Vision Master Application
• OBM Small Group Checklist
• OBM dental/vision employee application

2-50 & 51+

• PA enrollment form

2-50

• COBRA election form
• NJ EOI form
• Enrollment form

2-50

• ACH Instructions
• USAble Census Template
• Employee Enrollment Form

• USAble Change Form