Enrollment Kit - premier access (dental & vision)
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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 Premier Access' case submission requirements.
- Employer Application: The application should be completed and signed by the client and the broker.
- Employee Applications and Waivers: An enrollment application or waiver form from all employees eligible for coverage. Waivers must comply to minimum participation requirements.
- Deposit: A check from the employer that will be applied to the first month's premium.
- Prior Carrier's Billing Statement: A copy of the most recent billing statement from the prior carrier, if there is prior coverage.
- COBRA Information: A list of all former employees/depenedents on COBRA which includes the qualifying event reason and qualifying date of COBRA coverage, plus a copy of the COBRA election statement(s).
- State Wage and Tax Withholding Statement (DE-9C): For groups with 50 or fewer eligible employees, a copy of the employer's most recent quarterly statement is required.
- Broker Agreement
- Business Associate Agreement
| After approval, prior carrier termination letter must be submitted by the employer or broker. |
For other useful and older documents, please refer to the Forms database.