Enrollment Kit - ALLSTATE BENEFITS (medical) NV



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This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.

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 National General Benefit Solutions’ case submission requirements.
  • Implementation Questionnaire
  • Census Attestation
  • Self-Funded Program Employer Agreement
  • Business Associate Agreement
  • Administrative Services Agreement
  • Network Agreement
    • Aetna Network Services Agreement
    • Cigna Network Services Agreement
  • Health Care Reform Act
  • Allied ACH Authorization Form
In addition to the above, National General must also receive:
  • A complete census showing all active employees, even new hires who are in the waiting period
    • Next to each name, please indicate whether they are full time or part time, and if they are waiving or enrolling
  • Copy of groups most recent State Quarterly Wage and Tax Report, including pages that list each employee by name and their earnings
  • Employee waivers, if not already sent in with applications (only need section B of first page completed for waivers)
  • Final Signed Quote with plan election - to be signed by employer (last page of quote)
  • Should you have any questions during the appointment process, please call the National General licensing department at 888-659-1859, Option 2, or email
  • Even if you are not waiving the waiting period, National General still needs an enrollment or a waiver for all full-time employees. If you are not waiving the waiting period and a person waives at enrollment, they cannot enroll until the group's next year open enrollment - SEE CENSUS ATTESTATION FORM FOR FULL GUIDELINE
  • The rates that are signed off do not include the PCORI fee ($2.26 per coved life per year combined)
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.