Individual and Group Product Forms

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New Products Have New Forms
For Activate^SM, Innova^SM and Engage^SM business, use these new forms only. Do not use the forms listed below for these products.

Set up automatic deposits for your commission payments:
Authorization Agreement for Electronic Funds Transfer (Fillable PDF)

Creditable Coverage Notice Forms

Micro Group Forms

Community Group (2-50) Group Master Application and Benefit Selection Insert (Effective Dates of 7/08 and beyond)

Community Group (2-50) General Forms

Employee Enrollment & Change Form (PDF)
- English Version
- Spanish Version
Delayed Enrollment Exception Request (fillable PDF)
Request for Proposal (PDF)
Affidavit of Qualifying Domestic Partnership (PDF)
Waiver
- English Version (PDF)
- Spanish Version (Fillable PDF)
Newborn Application (PDF)
Employee Cancellation Form (PDF)
Selections Basic Employee Cancellation Form (PDF)
Personal Choice Account Employer Application (PDF)
Group Size Certification (PDF)

Notices & Disclosures

Groups of 51+ Employees

Merit & Experience Group (51+) Group Master Application and Benefit Selection Insert (Effective Dates of 7/08 and beyond)

Merit & Experience Group (51+) General Forms

Employee Enrollment & Change Form (PDF)
- English Version
- Spanish Version
Delayed Enrollment Exception Request (fillable PDF)
Request for Proposal (PDF)
Affidavit of Qualifying Domestic Partnership (PDF)
Waiver
- English Version (PDF)
- Spanish Version (Fillable PDF)
Newborn Application (PDF)
Employee Cancellation Form (PDF)
Selections Basic Employee Cancellation Form (PDF)
Personal Choice Account Employer Application (PDF)

Notices & Disclosures

Annual Notification

Individual Plans

Application for Individual Coverage (PDF)
Application for DentalOne (PDF)
Pre-Sale Disclosure List for Individual Plan Members (PDF)
Newborn Application (PDF)
Non-Smoker Certification Form (PDF)
Standard Health Questionnaire (PDF) - for coverage effective beginning 4/1/08
Electronic Funds Transfer (PDF)
Request to Change Form (PDF) (for existing Regence Individual Plan members only)

Medicare Plans

Regence MedAdvantage, Regence MedAdvantage + Rx Core, Regence MedAdvantage + Rx Classic and Regence MedAdvantage + Rx Enhanced, and Regence MedAdvantage + Rx Enhanced

Enrollment Form

Short Enrollment Form (for existing members to upgrade their plan)

2008 (PDF)
2009 (PDF) (not available yet)

Medicare Supplement

Asuris Medicare Script

Enrollment Form

Short Enrollment Form (for existing members to upgrade their plan)

2008 (PDF)
2009 (PDF) (not available yet)

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