Completed Employer Enrollment Form - Employer must also sign the Association and Trust Membership Agreement located on the back of the application. Please use corresponding application for corresponding product.
Employer Application - Dental PPO and Vision
Employer Application - Dental IndemnityPlus and Vision
Employer Application - PPO & Access Vision Plans
- Completed Employee Enrollment Form - Include refusal of coverage section or Quick Enroll Census
Employee Enrollment Form - Dental Only
Employee Enrollment Form - Dental Only (Espanol)
Employee Enrollment Form - Dental and Vision
Employee Enrollment Form - Dental and Vision (Espanol)
Employee Enrollment Form - Vision Only
Employee Enrollment Form - Vision Only (Espanol)
Dependent coverage for Domestic Partners:
If the employer elects coverage for domestic partners, please include a letter from employer
If the employee chooses to insure a domestic partner as a dependent, an "Affidavit of Domestic Partnership" must also be submitted with the employee enrollment form
Payroll - Required for all group sizes if company is a spin-off
Eligible Owners and Partners - Indicate the names of eligible owners or partners who do not appear on the quarterly wage report and provide owner/partner statements
Quarterly Wage Report - No wage report is needed for groups with 5 or more enrolling. For groups of less than 5 enrolling - Indicate on the Quarterly Wage Report which employees are:
Proof of Prior Coverage - Submit the most recent invoice indicating the original effective date of coverage
Benefit Representative Statement - Located on the back of the employer enrollment form
Employer Check - Made payable to "BEST Life and Health Insurance Company" for the first month’s estimated cost
Copy of Dental Proposal provided by BEST Life.
Agent Appointment Form and copy of license (if applicable)
There is a $20 monthly administration fee for groups with less than 6 employees enrolling for dental.