See other forms for Asuris Advance^SM and Preferred Plans

Note: These forms are the most common ones that you'll need. Not all online forms are ready yet for these new products, but we'll add them here as they become available.

• Micro Group Forms
  • Micro Group Request for Proposal (PDF)
  • Micro Group Employer Documentation (PDF)
• Cancellation Request Form
• Spreadsheet Enrollment Procedure and Template (Groups 2+) (XLS)
• Group Master Applications - Eff. 01/01/12 through 06/30/2012
  • Groups 1-99 Employees
  • Groups 100+ Employers 
• Group Master Applications - Eff. 07/01/12 and beyond
  • Groups 1-99 Employees
  • Groups 100+ Employers
• Dual Option Guidelines
  • 2012 Dual Option Guidelines (Groups 51+) - Eff. 01/01/12 and beyond
• Dual Option Matrices - Eff. 07/01/10 through 12/31/11
  • 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 Matrices - Eff. 01/01/12 and beyond
  • Embark HSA 2.0 Dual Option Matrix (Groups 10-50) (PDF)
  • Embark Dual Option Matrix (Groups 25-50) (PDF)
• Group Change Notification (PDF) NEW!
• Request for Proposal (PDF)
• Renewal and Maintenance Change Request
• Application for Enrollment/Change - Eff. 01/01/12 and beyond
• Application for Enrollment/Change (Spanish) (PDF)
• Application for Enrollment/Change (Groups 100+ Self Insured) - Eff. 01/01/12 and beyond
• Delayed Enrollment Exception Request coming soon
• Waiver Form
• Verification of Employment
• Affidavit of Qualifying Domestic Partnership
• Affidavit of Qualifying Incapacitated Dependent Eligibility
• Online Enrollment Set-Up Checklist (PDF)
• Employer Center Setup Form
• Surepay Authorization Form
• Authorization for Use and Disclosure of Protected Health Information

Spanish Language Forms / Formularios en Español
Currently available for Embark only

• Authorization to Disclose Health Information / Autorización para Divulgar Información Protegida de Salud