Employer and Employee Tools and Documents.

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Employer and Employee Tools and Documents	Form #	Revised
Applications
Change of Coverage Application	ECAFR1226CEN	6/09
Small Group Enrollment Application	BCASH3515C	07/08
Employee Addition Application (Existing Group)	8480	10/09
Employee Addition Application (Spanish)	8480SP	02/08
Employer Application-EmployeeElect & EmployeeChoice (2-50)	ECAFR2042CEN	10/09
Employer Appliction-EmployeeElect (51-99)	ECAFR2044CEN	10/09
BeneFits - Employer Application	ECAFR2043CEN	03/09
Employer Tools and Documents
EmployeeElect
2-50 EmployeeElect Plan Change Request Form, All Plans	ECAFR1223CEN	10/09
2-50 EmployeeElect Plan Change Request Form, Single/Designated	ECAFR1224CEN	10/09
51-99 PCRF, All Plans	10221CABEN	10/09
51-99 PCRF, Single/Designated	10220CABEN	10/09
Renewal Options EmployeeElect	ECASH2260CEN	02/08
Renewal Options EmployeeElect (Spanish)	ECASH2260CSP	03/08
EmployeeChoice
EmployeeChoice Plan Change Request Form	ECAFR1225CEN	5/09
EmployeeChoice	10915	10/08
BeneFits
BeneFits Plan Change Request Form	ECAFR1222CEN	5/09
BeneFits portfolio	10916	10/08
Renewal Options_BeneFits	ECASH1801CEN	02/08
Renewal Options_BeneFits (Spanish)	ECASH1801CSP	02/08
Forms
Rapid Quote Request (all Small Group plans)	BCAFR3549C	03/10
Information Change Form	10262CAMEN	07/09
EmployeeElect – How to Request Changes	ECASH1218CEN	05/09
Benefits How to Request Changes	ECASH1792CEN	02/08
HSA Employer Group Initiation Form (Chase)	PNA-214	10/09
HSA Agreement	ECALT2715C	04/08
Agent Checklist	12239CABEN	01/10
Check by Fax	12238CABEN	03/10
Phone Addendum	12377CABEN	01/10
Employer's Statement of Understanding 2-50	12250CAEEN	01/10
Exceptions to Standard Enrollment/Translator's Statement	12249CAMEN	01/10
Request for Print Renewal Paperwork/Fax Back Form	ECASH1793CEN	02/08
Benefit Modification Inquiry Form	12248CABEN	01/10
Other
360 Health Total Health Solutions brochure	ECABR1281C	11/09
Group Administrator Manual-(EmployeeElect, EmployeeChoice, BeneFits)	ECABR1839CEN	10/09
EmployerAccess Quick Reference Guide	ECASH2528C	03/08
EmployerAccess User Manual (Not a stocked item)	ECAHB2959C	06/08
Medicare Part D - Side 1 Employer Notice; Side 2 Creditable vs. Non- Creditable Coverage	ECAFR1162CEN	3/10
Privacy & Security Brochure	BCABR0818C	07/08
Privacy & Security Slick	BCASH3234C	07/08
Rising Costs, How does this affect my business?	ECASH1220CEN	03/08
Eligibility Statement (formerly Employer Sole Proprietor Statement)	12252CAEEN	01/10
Cal-Cobra/Cobra/Medicare Survey	N/A	N/A
HSA Admininistrative Guide for SG Employers	ECABR238C	05/08
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Employee Tools and Documents
Employee Access
Applications - BeneFits
BeneFits - Employee Application	MCAFR1168CEN	03/09
BeneFits - Employee Application (Spanish)	MCAFR1168CES	03/09
BeneFits - Employee Application (Chinese)	MCAFR1168CEC	03/09
BeneFits - Employee Application (Korean)	MCAFR1168CEK	03/09
BeneFits - Employee Application (Tagalog)	MCAFR1168CET	03/09
BeneFits - Employee Application (Vietnamese)	MCAFR1168CEV	03/09
EmployeeElect / Choice
Employee Application-EmployeeElect and EmployeeChoice (2-50)	MCAFR1167CEN	10/09
Employee Application-EmployeeElect and EmployeeChoice (Spanish)	MCAFR1167CES	03/09
Employee Application-EmployeeElect and EmployeeChoice (Chinese)	MCAFR1167CEC	03/09
Employee Application-EmployeeElect and EmployeeChoice (Korean)	MCAFR1167CEK	03/09
Employee Application-EmployeeElect and EmployeeChoice (Tagalog)	MCAFR1167CET	03/09
Employee Application-EmployeeElect and EmployeeChoice (Vietnamese)	MCAFR1167CEV	03/09
Employee Application-EmployeeElect (51-99)	MCAFR1258CEN	10/09
Employee Application-EmployeeElect (51-99) (Spanish)	MCAFR1258CES	03/09
Employee Application-EmployeeElect (51-99) (Chinese)	MCAFR1258CEC	03/09
Employee Application-EmployeeElect (51-99) (Korean)	MCAFR1258CEK	03/09
Employee Application-EmployeeElect (51-99) (Tagalog)	MCAFR1258CET	03/09
Employee Application-EmployeeElect (51-99) (Vietnamese)	MCAFR1258CEV	03/09
EmployeeElect/Employee Choice How to Request Changes 2-50	ECASH1218CEN	02/08
HIPAA Forms
HIPAA Authorization Instructions	MCAFR1145CEN	02/08
HIPAA Authorization Instructions (Spanish)	MCAFR1145CSP	02/08
HIPAA Authorization Instructions (Chinese)	MCAFR1145CCH	02/08
HIPAA Authorization Instructions (Korean)	MCAFR1145CKO	03/08
SG HIPAA Authorization	MCAFR1169CEN	02/08
SG HIPAA Authorization Spanish	MCAFR1169CSP	02/08
SG HIPAA Authorization Chinese	MCAFR1169CCH	02/08
SG HIPAA Authorization Korean	MCAFR1169CKO	02/08
HIPAA Notice of Privacy	MCASH1150CEN	02/08
Claim Forms
Patient Claim Form	MCAFR1148CEN	02/08
Patient Claim Form (Spanish)	MCAFR1148CSP	02/08
Patient Claim Form (Chinese)	MCAFR1148CCH	02/08
Patient Claim Form (Korean)	MCAFR1148CKO	02/08
Pharmacy Claim Form (Lumenos Only)	N/A	N/A
Pharmacy Claim Form (Non-Lumenos)	N/A	N/A
Other
Conditions of Enrollment (Seasonal Coverage)	12253CAEEN	01/10
Conditions of Enrollment for Start-Up Companies	12378CAEEN	01/10
Custodial Parent Verification Form	MCAFR1147CEN	02/08
Custodial Parent Verification (Spanish)	MCAFR1147CSP	02/08
Custodial Parent Verification (Chinese)	MCAFR1147CCH	02/08
Custodial Parent Verification (Korean)	MCAFR1147CKO	02/08
Make an Informed Decision	ECASH1227CEN	02/08
Affidavit of Domestic Partnership	MCAFR1146CEN	02/08
Affidavit of Domestic Partnership (Spanish)	MCAFR1146CSP	02/08
Affidavit of Domestic Partnership (Chinese)	MCAFR1146CCH	02/08
Affidavit of Domestic Partnership (Korean)	MCAFR1146CKO	02/08
Change of Beneficiary and/or Name Form	MCAFR2653B	02/08
Seguro de vida - Designación de beneficiario/ Cambio de nombre (Change of Beneficiary and/or Name Form - Spanish)	MCAFR2698BSP	02/08
Small Group Life Enrollment Form for Existing Employees and/or Beneficiary Designation Form	MCAFR2658B	02/08
Absolute Assignment Form	MCAFR2657B	03/08
Evidence of Insurability	MCAFR2701B	02/08
Women's Health Cancer Rights Notice	MCASH1151CEN	02/08
Grievance Procedure Notice	MCASH1152CEN	11/08
Surround yourself - A 360° Health® small group member guide	MCABR3625C	08/08
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