Enrollment Information

Group Enrollment Forms

2020 Enrollment Checklist Go to SGMP
2020 PBC Group Master Application form Small Group Marketplace (SGMP) Primer
2020 Benefit Selections 2019 Deadline Calendar 
2020 Deadline Calendar  Renewal Re-Rate Process
2019 Enrollment Checklist 2020 Double Choice Options
2019 PBC Group Master Application form 2020 Triple Choice Options
2019 Benefit Selections 2019 Dual and Triple Choice Options
2019 Dental Selection Worksheet Deductible Credit Process
Late Enrollment Acknowledgement Form Deductible Credit Form
2019 Deadline Calendar  Ordering Member ID Cards
Enrollment Census Template (Required) Member Enrollment and Change Form
Electronic funding authorization (HSA) Group Size Attestation

 

Member and Other Enrollment Forms

Member enrollment and change application Other coverage questionnaire enrollment
Member enrollment and change application (Spanish version) Personal funding accounts enrollment and change application
Affidavit of domestic partnership group plans Request for certification of disabled dependent
Deductible credit form Waiver of coverage
Enrollment spreadsheet (in lieu of member enrollment applications) Transition of care form
HIPAA pre-existing change notice and instructions Quick reference guide for plan administrators
HIPAA pre-existing change notice and instructions (Spanish version) Enrollment Exception Request

 

Member, UMB Bank Forms

UMB HSA beneficiary designation form UMB HSA funds transfer
UMB HSA name change request form HSA expense manual claim form
UMB HSA account closure/withdrawal request