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RBG, PALM BEACH - FORMS
HUMANA RELEASED DOWNLOAD
Employer Enrollment
2-99 NB Sold Case Checklist

Description:
Checklist of required enrollment documents (pdf , 97k)

9/5/2013   Download
ACH Authorization Form

Description:
Form for one time payment upon New Case Installation (pdf , 80k)

9/5/2013   Download
EGA Dental

Description:
Dental Only Master Application (pdf , 76k)

9/5/2013   Download
EGA Dental-Vision-Life

Description:
Master app for dental, vision & life only (pdf , 700k)

9/5/2013   Download
Eligibility Certification Form

Description:
Complete for employees not listed on most recent tax & wage report (pdf , 110k)

9/5/2013   Download
H S A Product Plan Selection

Description:
Required on all sold groups that select an H S A product (pdf , 214k)

9/5/2013   Download
Life Plan Selection

Description:
Employer app for Life Coverage (pdf , 64k)

9/5/2013   Download
Multi Location Form

Description:
Required for all sold groups who have more than one location (pdf , 81k)

9/5/2013   Download
STD LTD Employer App

Description:
Master App for STD and LTD (pdf , 77k)

9/5/2013   Download
Vision Employer App

Description:
Master App for Vision Coverage (pdf , 46k)

9/5/2013   Download
Employee Enrollment
Employee App

Description:
2-99 Lives (pdf , 336k)

9/5/2013   Download
Employee App Dental-Vision-Life

Description:
EE form for dental, vision and life (pdf , 288k)

9/5/2013   Download
Life Beneficiary Form
9/5/2013   Download
Claims
Medical Claim Form
9/5/2013   Download
Prior Carrier Deductible form

Description:
Once group is issued- employees can complete this for prior carrier ded credit (pdf , 28k)

9/5/2013   Download
Rx Claim Form
9/5/2013   Download