Enrollment Kit - Choice builder (Ancillary)
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Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval. The following list outlines Choice Builder’s case submission requirements.
- Employer Application
- Employer Application
- Employer must have a 9-digit Federal Tax ID Number (cannot be SS#).
- Owner/Partner Statement
- Required if owner(s) not shown on the quarterly/annual wage report with a full-time wage (current state minimum wage multiplied by number of hours to be considered eligible then multiplied by 13 weeks; state requirements - CA: 20+ or 30+ hours per week.
- Current Dental Carrier Billing (for companies with 10+ eligible who are electing Dental PPO).
- Submit copy of current billing statement and statement from 12 months prior in order to waive the waiting period for major services (statement from 12 months prior required for Orthodontic – must show Orthodontic coverage). May not apply to all carriers.
- Minimum Premium Deposit Check:
- Employer may submit a copy of the group’s premium deposit check, payable to ChoiceBuilder at case submission. Original check(s) or completed ACH Form for at least 90% of total premium due must be received by the underwriter prior to case approval.
- Section 125 (POP) – Add an additional $100 one-time fee to the premium deposit.
- COBRA premium is not required, but if submitted, include a separate check from the employer or COBRA enrollee payable to: Choice Builder.
- Employee Applications
- Employee Enrollment Application (and dependent waivers, if dependents not enrolling)
- Employee Change Request Form - Effective 1/1/2022
- Disabled Dependent Certification– Must be completed for dependent child(ren) over the eligibility age and not a full-time student.
- First Case only – (required for broker(s) signing the Employer Application
- Employer Application (see above).
- Agent Agreement
- Broker Licensing Form - Eff. 11/1/2019
- Copy of Broker License
- Carrier Licensing Form
- Case Submission Acknowledgement
- Required anytime a case is submitted to Choice Builder on or after the requested effective date. Disclaimer to members stating that they will not receive ID cards or other materials on time, and that it may take some time to show up in the carrier's system. Not required if case is submitted well ahead of time.
- CB Initial Payment Form (One-Time ACH) - Effective 1/1/2022
After approval, prior carrier termination letter must be submitted by the employer or broker.
For other useful or older documents, please refer to the Forms database.