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Applications & Forms

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

Individual Medical

Group Medical

Group Application

New! We've combined our coversheet and application into one PDF that can be used for all group sizes and both pre-ACA and post-ACA plans. We hope this makes the application process easier for you and your groups.

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 combined forms are listed below.

Large Group (51+ employees)
Idaho Universal Group Application, Cover Sheet, & Health Statement Addendum online-fillable form 3-1157C
Self-Funded (ASC), Trusts, Associations, etc.
Idaho Universal Group Application, Cover Sheet, & Health Statement Addendum online-fillable form 3-1157C
Small Group Grandfathered and Grandmothered
Idaho Universal Group Application, Cover Sheet, & Health Statement Addendum online-fillable form 3-1157C
QHP
Idaho Small Employer Application & Cover Sheet online-fillable form 3-1157C

Other Group Forms

Small GroupLarge GroupForm DescriptionForm #
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

Resource Center

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