Forms / Documents for Asuris NW Health Brokers & Agents


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Use the Right Forms
For Motivate^SM, Embark^SM, Vantage^SM, HSA Healthplan 2.0^SM and Asuris Pledge^SM business, use these forms only. Do not use the forms listed below for these products.

For Asuris Advance^SM and Preferred Plans

Set up automatic deposits for your commission payments:
Authorization Agreement for Electronic Funds Transfer

Creditable Coverage Notice Forms

Important Note: 2012 Product Changes
Effective January 1, 2012, some Asuris products will be discontinued or closed to groups sized 1-99. Please see the Product Transition Page for more information.

Micro Group Forms

Micro Group Request for Proposal (PDF)

Community Group (1-50) General Forms

Affidavit of Domestic Partnership (PDF)

Affidavit of Qualifying Incapacitated Dependent Eligibility

Delayed Enrollment Exception Request

Waiver Forms

English Version (PDF)

Group Size Certification (PDF)

Notices & Disclosures

Groups of 51+ Employees

Merit & Experience Group (51+) Group Master Application and Benefit Selection Insert (Effective Dates of 03/09 and beyond)

General Forms

Affidavit of Domestic Partnership (PDF)

Affidavit of Qualifying Incapacitated Dependent Eligibility

Delayed Enrollment Exception Request

Annual Notification (PDF)

Waiver Forms

English Version (PDF)

Notices & Disclosures

Agent Change Request - Change the agent of record for a health coverage plan

Legacy Individual Plans - use for current members only

Medicare Plans

Agent Change Request - Change the agent of record for a health coverage plan

Asuris TruAdvantage + Rx Enhanced (PPO), Asuris TruAdvantage + Rx Classic (PPO) and Asuris TruAdvantage (PPO)

Enrollment Form 2011

Asuris Medicare Script (PDP)

Enrollment Form 2011

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