Get Small Group New Business Inquiry Form

Filling out the Small Group New Business Inquiry Form online can streamline your submission process and ensure all necessary information is captured accurately. This guide provides step-by-step instructions to assist you in completing the form effectively.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to access the inquiry form and open it in your browser.
2. Begin by filling in the group information. Enter the 'Group Name,' 'Date Inquiry Submitted/Faxed,' and indicate if this is a 'Takeover' by selecting 'Yes' or 'No.'
3. Provide details about the number of employees. Include the 'Total Full-time Employees,' 'Total Part-time Employees,' and the 'Total Enrolling Employees' with their respective numbers for spouses and dependent children.
4. Input the 'Requested Effective Date' and the 'Group’s ZIP Code,' ensuring the ZIP Code field is marked as mandatory.
5. Fill in the agent information, including the 'Agent Name,' 'Agent ID Number,' 'General Agent,' and 'Phone Number.' You also need to add the 'Fax Number' for submission.
6. Answer the questions regarding COBRA/State Continuation and whether all applicants are covered by workers’ compensation by selecting 'Yes' or 'No.'
7. Detail any medical conditions present in the group, including the number of pregnancies and due dates. You will need to include specific diagnosis and date of onset, treatment, prognosis, and medications for both applicants and dependents.
8. Review the 'General Concerns and Questions' section, providing any relevant inquiries you may have regarding the process.
9. After completing the form, ensure all information is accurate and complete. You can then save changes, download a copy, print, or share the completed form as necessary.

Complete the Small Group New Business Inquiry Form online today to ensure your inquiry is processed promptly.