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New Options for Affordable Health Insurance

Forms for Large Employer Groups of 50-100 Employees

 
Download Instructions:

The following applications and forms are in PDF format.  Adobe Acrobat Reader   software is required to view, print and search these PDF documents. Please download this free software on the Adobe Acrobat Web site. Please note that Blue Cross of Idaho does not provide Technical Support for Acrobat Reader Software. For technical support, please contact Adobe.  

 

 

APPLICATIONS & FORMS

FORM NO.

Application Cover Sheet for Group Dual Option (HSA)

3-128

Application for Medium/Large Employer Coverage

3-326

ASC Application/ Questionnaire for New Groups

3-437

ASC Group Health/Dental Enrollment Application 

3-307

ASC Group Health Enrollment Application

3-305

Employee Census Data

3-468

Employee's Waiver of Health Care Coverage

3-467

Group Questionnaire for New Groups - 51 or more employees

3-471

Large Group Health Application with Health Statement

3-300

Large Group Health Application without Health Statement

3-556

Large Group Health/Dental Enrollment Application with Health Statement

3-301

Large Group Health/Dental Application without Health Statement

3-393

Letter of Record 

3-302

Managed Care Group Questionnaire for New Groups 51 or More Employees 

3-243

Managed Care ASC Application/Questionnaire for New Groups

3-244