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
This short instruction sheet will walk you through the process of adding your new employees to your group health insurance plan. For clients not using My Benefit Link.
Use this form to give us your employee information. This is an updated form for the 2019 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 Healthcare Reform…get those forms click here
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.