Employer Forms
Group Benefits Manager's Manual Comprehensive guidance for handling Group-level changes.
| Form | Purpose |
|---|---|
Group Enrollment
 |
Used for EMPLOYEE updates to enrollment |
| Onilne Group Enrollment Form | Used for NEW ENROLLMENT/HIRES only. |
| Student Certification
|
|
| Incapacitated Dependent
|
Request for coverage, and medical certification |
| Domestic Partner Coverage | |
| Group Membership Update
|
Membership Changes |
| Small Group Certification
|
Small Employer Qualification |
| Small Group Certification: New Group
|
Small Employer Qualification for NEW GROUPS |
| Small Group Certification: Requalification
|
Small Employer Qualification for REQUALIFICATIONS |
| Small Group Certification: Transfer
|
Small Employer Qualification for TRANSFERS |
| Waiver of Group Health Insurance |
Used by spouses or partners to opt out of BCBSVT coverage |
VT Blue 65 (CMS, Credible/Non-Credible Coverage)
| Form | Purpose | |
|---|---|---|
| Creditable Coverage
(Group Letter) |
Information about 2010 Open Enrollment for drug coverage and Medicare Part D | |
| Non-Creditable Coverage
(Group Letter) |
Information about 2010 Open Enrollment for drug coverage and Medicare Part D | |
| CMS Creditable Coverage Guidance |
Important notice concerning prescription drug coverage | |
| CMS Model Creditable Coverage Notices (Word Doc) | Important notice concerning prescription drug coverage | |
| CMS Model Non-Creditable Coverage Notices (Word Doc) | Important notice concerning prescription drug coverage | |
| CMS Model Personalized Creditable Coverage Notices |
Important notice concerning prescription drug coverage | |
| Group Subscriber Medicare Supplement Application and Change Form |
Form for a group subscriber's changes | |
New Enrollment Instructions Membership Change Instructions
Note: The group enrollment form is used to notify us of membership changes.