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RBG, TAMPA-FT. MYERS - FORMS
HUMANA RELEASED DOWNLOAD
Employer Enrollment
ACH Authorization
4/21/2014   Download
Attestation/Late Business Form

Description:
To be submitted with Medical Groups submitted past the 20th of the Month (ocx , 189k)

7/15/2016   Download
Employer App (EGA) 2017
1/30/2017   Download
Employer App - 2016 Disability
7/15/2016   Download
Level Funded Sold Case Document
7/15/2016   Download
Employee Enrollment
Enrollment Form - 1-100 2016 Med, Dent, Vis, Life
7/15/2016   Download
Beneficiary Designation Form

Description:
To change or elect a new beneficiary. A copy should be kept with employer. (pdf , 51k)

7/15/2016   Download
Change Form 2016

Description:
To make changes to members currently enrolled. (pdf , 270k)

7/15/2016   Download
Enrollment Form - 1-100 2016 Dental, Vis & Life
7/15/2016   Download
Enrollment Form - Level Funded Premium ONLY
7/15/2016   Download
Enrollment Form 1-100 Spanish
7/15/2016   Download
Enrollment form 100+
7/15/2016   Download
Enrollment form 100+ Spanish
7/15/2016   Download
Administration
Group Maintenance Request

Description:
To amend the current contract, including waiting periods, plan changes, adding lines of coverage, etc. (pdf , 87k)

7/15/2016   Download
Renewal Date Change Form
7/15/2016   Download
Claims
Dental Claim Form
7/15/2016   Download
Life Claim Form
7/15/2016   Download
Mail Order Pharmacy Form
7/15/2016   Download
Mail Order Pharmacy Form Spanish
7/15/2016   Download
Pharmacy Claim Form
7/15/2016   Download
Pharmacy Claim Form Spanish
7/15/2016   Download
Vision Claim Form

Description:
For Out of Network Claims (pdf , 694k)

7/15/2016   Download
Other
100-299 Quoting Checklist

Description:
A list of required info to quote groups from 100-299 (doc , 69k)

4/21/2014   Download
51-99 Quoting Medical Questionnaire

Description:
For Quoting 51-99 cases with Humana (ocx , 57k)

4/21/2014   Download
Agent Business Transferal Form

Description:
To transfer a block of business from one agency to another (pdf , 153k)

7/15/2016   Download
Level Funded Premium Quote Request checklist
7/15/2016   Download
RBG HSA Trifold 2016
7/15/2016   Download