|
1099 Eligibility Verification
|
1/24/2014
|
Download
|
|
 |
ACH form
Description:
For drafting the first month's premium via ACH
(pdf
, 136k)
|
1/24/2014
|
Download
|
|
|
Aetna AFA - Employer Application
Description:
*Aetna AFA only
(pdf
, 610k)
|
1/17/2017
|
Download
|
|
|
Aetna AFA - NYHCRA DOH 4264
Description:
*Aetna AFA only
(pdf
, 24k)
|
1/17/2017
|
Download
|
|
|
Aetna AFA - NYHCRA DOH 4399A
Description:
*Aetna AFA only
(pdf
, 29k)
|
1/17/2017
|
Download
|
|
|
Aetna AFA - NYHCRA DOH 4399B
Description:
*Aetna AFA only
(pdf
, 23k)
|
1/17/2017
|
Download
|
|
|
Aetna AFA - Stop Loss Application 10-50 eligible
Description:
*Aetna AFA only
(pdf
, 12k)
|
5/4/2017
|
Download
|
|
|
Common Ownership Form
|
1/24/2014
|
Download
|
|
|
Employer Acknowledgment - Employer Waiting Period
Description:
required with all new business submissions
(pdf
, 56k)
|
1/24/2014
|
Download
|
|
|
Employer Representation - HSAs
Description:
When selling an HSA this form must be completed
(pdf
, 167k)
|
10/29/2012
|
Download
|
|
|
PEO Questionnaire
|
1/24/2014
|
Download
|
|
|
Small Group - Addendum - TAE
Description:
Total average employees form required for all new cases
(pdf
, 248k)
|
10/29/2012
|
Download
|
|
|
Small Group - Employer Application
|
1/16/2017
|
Download
|
|
|
Aetna AFA - Individual Medical Questionnaire
Description:
*Individual Medical Questionnaire for medical underwriting
(pdf
, 708k)
|
4/13/2017
|
Download
|
|
|
Dependent to Age 30 form
Description:
Required for dependents ages 26-30
(pdf
, 128k)
|
1/24/2014
|
Download
|
|
|
Employee Enrollment/Change Form (2-100)
|
4/13/2017
|
Download
|
|
|
Employee Enrollment/Change Form (51-100)
|
1/24/2014
|
Download
|
|