Get Included

Filling out the Included form for a small employer group application can be straightforward if you approach it step-by-step. This guide will provide you with the clarity needed to complete the form accurately and efficiently.

Follow the steps to complete your application smoothly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section I: Policyholder Information. Here, you will provide the full legal name of your company, Tax Identification Number, and contact information including the main and mailing addresses.
3. Fill in the type of organization. Select from corporation, partnership, proprietorship, or other, as applicable. Also, specify the nature of your business and the Standard Industry Classification (SIC) code.
4. Indicate the number of full-time employees in your company and those to be insured. This is crucial for determining your eligibility and correct coverage.
5. In Section II, specify your desired health benefits options. Choose from Advantage Direct Access plans or OMNIA plans, and also consider any pediatric dental options if applicable.
6. Proceed to Section III, where you will answer questions regarding current and prior coverage along with any ongoing health plans for employees.
7. In Section IV, you must provide the broker information and have them sign where required. Ensure that this section is completed fully for processing.
8. Finally, review Section V for signatures. The Officer, Partner, or Proprietor must verify the information, sign the document, and date it accordingly.
9. Make sure all required documents are prepared for submission, including the first month’s premium and any necessary verification, before sending the completed application.
10. Once all fields are completed accurately, save your changes, download a copy for your records, and proceed to submit the application as instructed.

Complete your application online to ensure a smooth health benefits coverage process.