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Individuals

• 2023 IHC Application
• 2022 IHC Application
• 2021 IHC App with Payment Info
• Davis Vision Reimbursement Claim Form
• HIPAA Authorization for Disclosure of Health Info
• Out of Pocket Maximum Reimbursement Form

2-50

• Medical/Dental/Vision Enrollment/Change Form

2-50

• Eligibility Letter Template
• Enrollment Spreadsheet
• Employer Application
• Employee Application

51+

• Midsize/Large group enrollment form
• 51+ Master Application
• Horizon Large Group Certification

Individuals

• 2023 IHC Spanish enrollment form
• 2023 IHC app- Spanish
• 2023 IHC app
• 2023 IHC BOR
• 2023 IHC Dental & Vision App- Spanish
• 2023 IHC Dental & Vision App
• 2022 IHC Application
• 2022 IHC Application- Spanish
• 2022 IHC Application-Dental/Vision
• 2022 IHC Termination Form
• Individual Term Form
• Away from Home Care Services Application
• Spanish Version: Special Enrollment Documentation Requirements
• Auto Pay Application

2-50

• 2023 SEH Master Application
• 2023 SHOP Master Application
• Level Select Master App
• 2022 SEH Master App
• 2022 SHOP Master App
• HSA Funding Form
• NEW HSA Setup Form effective 1/1/19
• Declaration of Understanding *New June 2021*
• Spanish Version: Waiver of Coverage
• Spanish Version: Enrollment Change Form
• Spanish Version: New Group Application
• Highlighted Small Group Enrollment/Change Request
• Small Employer Common Ownership Certification
• 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

Individuals

• Enrollment Change Form

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

2-50 & 51+

• COBRA General Notice
• COBRA Model Election Notice

51+

• Enrollment Form

2-50

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

Individuals

• 2021 PA IHC app
• NJ IHC app
• Payment Form for IHC
• Individual BOR template

2-50

• OXLF Enrollment form with MUW
• EE Enrollment Form
• 2022 OHI Master App
• 2022 OHP Master App
• Group Contact/Address/Name Change Form
• Waiver
• 2021 Certification
• Oxford Verification Form
• Common Ownership Form for Affiliated Groups

51+

• 51+ EE Enrollment Form

2-50 & 51+

• All Savers HIPAA form
• All Savers NJ 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

• Enrollment form

2-50

• ACH Instructions
• USAble Census Template
• Employee Enrollment Form

• USAble Change Form