These printable forms are in PDF format. To read and print them, you need the free
Adobe Acrobat Reader (which may already be installed on your system). If you do
need to install it, click below.
Complete and Print Forms
You can complete all of the forms listed below on your computer before you print.
Simply click on the form and type in the appropriate information. Then print the
completed form, sign and mail to the address indicated on the form.
Enrollment
Member Enrollment Form
This form is used to add new members to an HMO or POS group policy.
Member Change Form
This form is used to make changes to an existing member’s coverage, to add or remove
dependents, to change demographic information and to cancel coverage.
COBRA (For Employers) Forms
COBRA forms are currently available under the Federal COBRA site at
www.dol.gov/dol/topic/health-plans/cobra.htm.
The American Recovery and Reinvestment Act of 2009
The economic stimulus package signed into law by President Obama includes important new COBRA compliance obligations. The new law, known as the American Recovery and Reinvestment Act of 2009 (Act), creates detailed new rights to COBRA premium assistance for employees (and their families) who are involuntarily terminated between September 1, 2008 and December 31, 2009. It also adds an option to change enrollment to a different plan. Employers, insurers and administrators will need to implement the COBRA provisions in this legislation on very short notice. The Act is effective on the date of enactment (February 17, 2009) and provides premium assistance, for most plans, as of March 1, 2009. For an overview of the Act, please click on the link below.
American Recovery and Reinvestment Act of 2009 overview.