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RBG, JACKSONVILLE - FORMS
AETNA RELEASED DOWNLOAD
Employer Enrollment
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 , 11k)

1/17/2017   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
Employee Enrollment
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