See other forms for legacy Individual Plans (Asuris Core Plan^SM, Asuris Clarity^SM 70/50 Plans, Asuris HSA Healthplan, Asuris HSA Comprehensive Healthplan), Medicare, Asuris Advance^SM and Preferred Plans

Individual Plans

• Asuris Emerge Pre-Sale Brochure (PDF)
• Application (PDF)
• Health Questionnaire (PDF)
• Proof of Exemption from Standard Health Questionnaire (PDF)
• Rate Sheet (PDF)
• EFT/Surepay Form (PDF)
• Domestic Partner Affidavit (PDF)
• Affidavit of Incapacitated Dependent Eligibility (PDF)
• Newborn Application (PDF)
• Non-Smoker Certification Form (Fillable PDF)
• Emerge Plan Change Request (PDF)

Group Plans

• Spreadsheet Enrollment Procedure and Template (Groups 2+)
• Group Master Applications
  • Groups 2-99 Employees
    
  • Groups 100+ Employees
• Dual Option Matrices & Guidelines - Effective dates 07/01/09 and beyond
  • Embark/Vantage/HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
  • Embark/Vantage Dual Option Matrix (Groups 25-50) (PDF)
  • Embark/Vantage/Motivate Dual Option Matrix (Groups 25-50) (PDF)
  • Dual Option Guidelines (Groups 51+)
• Micro Group Request for Proposal (PDF)
• Application for Enrollment/Change (PDF)
• Application for Enrollment/Change (Spanish) (PDF)
• Delayed Enrollment Exception Request
• Waiver Form
• Affidavit of Qualifying Domestic Partnership (PDF)
• Affidavit of Qualifying Incapacitated Dependent Eligibility (PDF)
• Online Enrollment Set-Up Checklist (PDF)
• Employer Center Setup Form
• Surepay Authorization Form
• Authorization for Use and Disclosure of Protected Health Information (PDF)

Spanish Language Forms / Formularios en Español
Currently available for Motivate, Embark and Vantage plans only

• Waiver Form / Formulario de renuncia
• Authorization to Disclose Health Information / Autorización para Divulgar Información Protegida de Salud