Forms

Employer Applications

[2014 Small Employer Application](2014 Small Employer Application.pdf) <50 Employees [2014 Large Employer Application](Large Group Application.pdf) >50 Employees

2014 PPO Benefit Highlight Sheets

750 PPO Plan 1000 PPO Plan [1500 PPO Plan] (AGC01-141500_PPOHighlightSheet.pdf) 2500 PPO Plan 5000 PPO Plan [Delta Dental](Delta Dental Summary of Benefits 2014.pdf) [VSP](VSP AGC ID.pdf)

2014 Employer Forms

Waiver [Leave of Absence Request](LOA Form.pdf) [Self-termination of employee or dependent form](Term Form.pdf)

2014 Summary of Benefits and Coverage (SBC)

  • 750 PPO Plan
  • 1000 PPO Plan
  • 1500 PPO Plan
  • 2500 PPO Plan
  • 5000 PPO Plan

Medical and Prescription Drug Forms

  • [Blue Cross of Idaho Claim form]( Member Claim Form.pdf)
  • Prescription drug claim form – CVS
  • Census
  • Application for Group Coverage
  • Group Participation Agreement
  • Waiver
  • Declaration of Common Law Marriage
  • Leave of Absence Request

Met Life and Disability Forms

  • Supplemental Group Application
  • [Employee Enrollment Form with medical plan]( MetLife Enrollment Form.pdf)
  • [Employee Enrollment Form without medical plan]( MetLife Enrollment Form- LIFE ONLY APP.pdf)* [Benefi-ciary Change Form]( Beneficiary Change Form - Life ADD.pdf)
  • [Life Buy-up rate worksheet](Life Buy-up rate sheet revised.pdf)
  • [Eligibility Change Form]( Metlife - Change Form.pdf)
  • Privacy Notice
  • Statement of Health
  • [Short-term disability buy-up rate worksheet]( STD Buy-up rate sheet 2013.pdf)
  • Short-term disability Claim form

Broker/Agency Forms

  • [Quoted group checklist](Quoted Group Check List.pdf)
  • [Sold group checklist](Sold Group Check List.pdf)
  • Group participation checklist
  • Census form
  • [Small Group Application form]( 2014 Small Employer Application.pdf)
  • [Large Group Application form]( Large Group Application.pdf)
  • [Application for Group Coverage]( Group app for coverage.pdf)
  • Waiver
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