Broker Forms and Information

Contacts

Sales and Service Team Contacts

Information

ATNE Worksheet
Deductible and OOP Credit Information Flyer
Products and Services Brochure
Stress-Free Me Challenge

Broker/Agent Forms

Form Name
Broker Appointment Packet — Vision
Broker/Agent Commission Assignment Form
Broker New Group Submission Checklist
Direct Deposit Authorization Form – Brokers Only
Product Selection Sold Rate Form
Request for Quote – Brokers Only

Flexible Spending Account

Form Name
FSA Claim Form
FSA Election Form with Grace Period
FSA Election Form with Rollover Provision
FSA Eligible/Ineligible/OTC Expenses
FSA Medical Necessity Form
FSA Program Information
FSA Secondary Card Request
FSA — Step by Step
FSA Substantiation Form
FSA Worksheet

Groups and Individual

Form Name
Alternate Application Authorization
AR State Group Continuation Coverage Election Form
Authorization for Automatic Payments - Groups
Billing and Payment Authorization Form — IQChoice
Care Management Referral Form
Change Form
Coordination of Benefits Questionnaire
Designation of Personal Representative
Disabled Dependent Request for Extension of Coverage
Group Application for Coverage
Group Employee Application
Group Employee Application - ES
HRA Claim Form
Medical Claim Form
Medical Plan Selection Form
Medical Plan Selection Form - ES
Preventive Care Benefits
Preventive Care Benefits - ES
Request for Personal Health Information
Termination Form

Group Term Life

Form Name
Designation of Beneficiary Form
Group Life Insurance Claim Form
Group Life Insurance Health Statement
Group Term Life Fact Sheet

MediQ65

Form Name
MediQ65 Application for Coverage (to enroll in 2021 plans)
MediQ65 Payment Authorization Form
Notice of Replacement Questionnaire