Group Client Forms

Fax Cover Enrollment Transaction Authorization
Need to make an enrollment change? Use this cover sheet and fax your request to us securely at (888)287-3186

Broker of Record Letter
Many clients are initially surprised to find out that they can enjoy all the benefits of working with our firm without the hassle of changing insurance carriers. Hire us today by downloading the broker of record letter and faxing it to us at (888)287-3186. The process is seamless and free!

Company Census Form
Use this form to give us your employee information. This is an updated form for the 2014 ACA compliant plans. Please note that under the ACA we must collect dependent data such as date of birth and also tobacco user status of all members. The more accurate the information is, the more accurate your quotes will be! This can also be faxed to us at our secure fax (888)287-3186.

Physician Census List
Thinking about changing insurers but you’re unsure about the doctors in your proposed plan? Use this form to tell us which doctors, facilities or hospitals you want us to search for, and we will do a network comparison and a cross network analysis. Just complete and fax the form to us at (215)947-5478.

EXCHANGE NOTICE-FOR EMPLOYERS OFFERING COVERAGE
All employers are required to notify current and new employees about the new health insurance “exchanges” or marketplaces by October 1st 2013 and annually thereafter.  This form will make this task easier for you.

EXCHANGE NOTICE-FOR EMPLOYERS NOT OFFERING COVERAGE
All employers are required to notify current and new employees about the new health insurance “exchanges” or marketplaces by October 1st 2013 and annually thereafter.  This form will make this task easier for you. This form is specifically worded for employers who will no longer, or currently do not, offer employer paid coverage.

COBRA information and forms are available here.

Looking for PA Mini-Cobra information and notices? click here

Looking for Heathcare Reform…get those forms click here


 

Independence Blue Cross Enrollment Forms:

2017 IBC Small Group Employer Application
For small companies starting a new group plan
2017 IBC Small Group Employee Enrollment Form
For employees being added to a small group

2017 IBC Renewal Change Form
For an existing small group client changing plans at renewal

IBC Proof of Eligibility Form
For employees being added to a small group who are not on payrolls such as officers and owners

IBC Waiver of Coverage Form
F
or eligible employees to waive out of small group coverage

2017 IBC Preventative Services
2017 IBC Healthy Lifestyles


Please contact your Total Benefit Solutions account manager at (215)355-2121 for forms from other carriers or if you do not see the form you need.


Individual Client Forms

Getting enrolled Total Benefit Solutions Inc has designed a custom form for our clients to use for enrolling on the health insurance marketplace. Using this form and submitting it to Total Benefit Solutions Inc  will enable our Marketplace trained and certified licensed independent brokers to assist you in the enrollment process from  the registration right through the enrollment! Remember as your independent broker we always work in your best interests,  not an insurance company. We represent you, our client and not an insurer or government agency.

Click the link below to open the form and get started!  When completed, just click the link to attach it to an email, or print and fax it to our toll free secure fax at 1 (888)287-3186. It couldn’t get any easier!

 

Looking for Healthcare Reform related forms? Click here.

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