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If you are an Individual or Family Member, please register here.

If you are a Medicare Advantage or Medicare Supplement member, please register here.

Applications & Forms

The following is a list of our online forms and applications. Looking for group sales literature?

Individual Medical

Group Medical

Group Application

We are excited to provide you with this new application.

Please be aware that the Idaho Department of Insurance requires that a cover sheet be submitted with the Idaho Universal Group Application. In addition you may need to submit a health statement addendum. Links to the appropriate forms are listed below the main application.

Idaho Universal Group Application - 3-1157

Large Group (51+ employees)
Self-Funded (ASC), Trusts, Associations, etc.
Small Group Grandfathered and Grandmothered
QHP

Other Group Forms

Small Group Large Group Form Description Form #
X X Dual Option Application Cover Sheet 3-128
X   Employee Census Data 3-468
X X Employee's Waiver of Health Care Coverage 3-467
  X Employer Application & Group Questionnaire for New Groups 51 or more Employees 3-550
X   Employer Application & Questionnaire for New Small Group Coverage 3-549
X X Group Contact Change Form 3-1146
X   Group Quoting System Excel Roster (.zip file)  
  X Idaho Large Employer Group Application Cover Sheet - Spanish 3-186S
X X SBC Attestation 3-325
X X Third Party COBRA Notification 3-1125
X   Universal Idaho Small Employer Application - Spanish 3-017S

Dental Standalone

Group Standalone Dental Enrollment Application 3-395

Statewide Schools

Statewide Schools ASC Health/Dental/Vision Enrollment Application 3-307SWS

Voluntary Vision

Group Voluntary Vision Enrollment Application 3-412

Additional Forms/Resources