Micro Group Forms

• Micro Group Request for Proposal (PDF)

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

• Group Master Application (2-50) (Fillable PDF)
• Benefit Selection Insert (2-50) (Fillable PDF)

Community Group (2-50) General Forms

• English Version (PDF)
• Spanish Version (Fillable PDF)

Notices & Disclosures

• Annual Notification (PDF)
• Pre-Sale Disclosure (PDF)
• Post-Sale Disclosure (PDF)
• Dental Privacy Practices (PDF)

Groups of 51+ Employees

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

• Group Master Application (Fillable PDF)
• Benefit Selection Insert (Fillable PDF)

General Forms

• English Version (PDF)
• Spanish Version (Fillable PDF)

Notices & Disclosures

• Annual Notification (PDF)
• Annual Notification (No Wait) (PDF)
• Pre-Sale Disclosure (PDF)
• Post-Sale Disclosure (PDF)
• Dental Privacy Practices (PDF)

Individual Plans

• Application for Individual Coverage (PDF)
• EFT (Electronic Funds Transfer form)
• Newborn Application (PDF)
• Standard Health Questionnaire (PDF) -- for effective dates prior to 4/1/08
• Standard Health Questionnaire (PDF) -- for effective dates 4/1/08 and later
• Non-Smoker Certification Form (PDF)
• Request to Change Form (PDF) (for existing Asuris Individual Plan members only)

Medicare Plans

Asuris TruAdvantage, Asuris TruAdvantage + Rx, and Asuris TruAdvantage + Rx Enhanced

• 2008 Enrollment Form
• 2008 Short Enrollment Form (for existing members to upgrade their plan)

• Medicare Supplement Application
• EFT (Electronic Funds Transfer form)

• 2008 Enrollment Form
• 2008 Short Enrollment Form (for existing members to upgrade their plan)