Enrollment Information

Group Enrollment Forms

2021 Enrollment Checklist	Go to SGMP
2021 PBC Group Master Application	Small Group Marketplace (SGMP) Primer
2021 Benefit Selections	Renewal Re-Rate Process
2021 Deadline Calendar	2020 Double Choice Options
Late Enrollment Acknowledgement Form	2020 Triple Choice Options
Enrollment Census Template (Required)	Deductible Credit Process
Electronic funding authorization (HSA)	Deductible Credit Form
Group Size Attestation	Member Enrollment and Change Form
Ordering Member ID Cards

 

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

2021 Personal Funding Account Setup Form	UMB HSA funds transfer
UMB HSA name change request form	HSA expense manual claim form
UMB HSA account closure/withdrawal request	UMB HSA beneficiary designation form