For your clients with 1-100 employees
- Employer Application (for businesses with 1 - 50 eligible employees)
- Employer Application (for businesses with 51 - 100 eligible employees)
- Employee Enrollment/Change Form (for businesses with 1 - 50 eligible employees)
- Employee Enrollment/Change Form (for businesses with 51 - 100 eligible employees)
- Automated Clearing House (ACH) New Business Request Form
- Evidence of Insurability Employee must complete this form for approval of Life Insurance Elections over the Guaranteed Issue Amount which is $20,000 for groups 2-9 employees, $75,000 for groups 10-25 employees and $100,000 for groups 26-50; or Late Enrollee for Life and/or Disability – an individual enrolling more than 31 days from the date first eligible is considered a late enrollee. Benefits are offered through Aetna.
Other Documents and Resources:
Innovation Health Private Exchange
- For customers with 1-50 eligible employees with new business dates after 4/1/2016 and existing business with renewals after 5/1/2016, administration must be completed using the Innovation Health Private Exchange. Please click here to visit the exchange.
- Note: Customers administered through a TPA will not be administered using the Innovation Health Private Exchange.
For your clients with more than 100 employees
- PPO Employee Enrollment/Change Form
- PPO Employee Enrollment/Change Form (Spanish)
- HMO Employee Enrollment/Change Form
- HMO Employee Enrollment/Change Form (Spanish)
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