Enrollment Information

Group Enrollment Forms

2019 Enrollment Checklist	Go to SGMP
2019 Deadline Calendar	Small Group Marketplace (SGMP) Primer
2019 PBC Group Master Application form	Renewal Re-Rate Process
2019 Benefit Selections	2019 Dual Choice Options
2019 Dental Selection Worksheet	2018 Dual Choice Options
Late Enrollment Acknowledgement Form	Deductible Credit Process
2018 Deadline Calendar	Deductible Credit Form
Enrollment Census Template (Required)	Ordering Member ID Cards
Electronic funding authorization (HSA)	Member Enrollment and Change Form
Group of One Attestation	Group Under 51 Attestation Form

 

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