Forms

Employer Enrollment Materials

Dental & Vision

1. Dental PPO Employer Application Word | PDF
2. TX Dental PPO Employer Application Word | PDF
3. IndemnityPlus Employer Application Word | PDF

Medical

1. National Health Solutions II Employer Application Word | PDF
2. TX Health Solutions II Employer Application Word | PDF
3. National High Deductible Health Plan Employer Application Word | PDF
4. TX High Deductible Health Plan Employer Application Word | PDF

Life

1. Group Life Insurance Employer Application Word | PDF
2. Portable Life Employer Application PDF

Vision

1. Stand Alone Vision Employer Application Word | PDF

Forms for Employers

1. Employer Group Roster Word
2. Termination Form PDF

Claim Forms

1. Dental Claim Form
   
2. Group Medical Claim Form
   
3. CareMark Prescription Drug Claim Form
   
4. HDHP Prescription Drug Claim Form
   
5. Vision Claim Form
   
6. Life Claim Form

COBRA

1. COBRA Form

Employee Form

1. Continuation of Coverage for Disabled Dependents Form PDF

DENTAL

1. Interactive Enrollment Card Online
   
2. Dental Only Enrollment Card Word | PDF
   
3. Dental/Vision Enrollment Card Word | PDF
   
4. Refusual of Dental Coverage Form Word | PDF
   
5. Affidavit of Domestic Partnership Form Word | PDF

MEDICAL

1. Health Solutions II Enrollment Form (National) Online | PDF
   
2. Health Solutions II Enrollment Form (Texas) Online | PDF
3. Health Solutions II Enrollment Form (Arizona) PDF
   
4. HDHP Employee Enrollment Form Online | PDF
5. HDHP Employee Enrollment Form (Arizona) PDF
   
6. Idaho Universal Enrollment Form (for all medical plans) Online | PDF
   
7. CareMark Mail Order Form
   
8. View a Current Drug List

VISION

1. Enrollment Card Online | PDF
   

LIFE

1. Essential Life Enrollment Form Word | PDF
2. Passport Life Enrollment Form Word | PDF
   
3. Flex Life Enrollment Form Word | PDF
   
4. Change of Beneficiary Word | PDF