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