Enrollment Kit - unitedhealthcare (medical)



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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 UnitedHealthc​​are’s case submission requirements.
  • Submit a check for one month’s premium payable to UHC (UnitedHealthcare) or submit applicable direct debit form. Please NOTE: Micro groups (under 3 eligible or 1 enrolled) are required to use the ACH form. That is the only option.
    • Scheduled Direct Debit Form - Dual Option 
    • Scheduled Direct Debit Form - Standalone HMO 
    • Scheduled Direct Debit Form - Standalone PPO & Specialty
Completed Employer Application and Product and Benefit Selection Form signed by employer and broker (dated within 90 days of effective date). Please note, only most current version will be accepted.​
  • Employer Application - Effective 1/1/2023​​ (Current)
  • Group Acceptance/Change Form - Product and Benefit Selection Form - Effective 4/1/2023
  • Employee Enrollment Form / Waiver of Coverage​
    • ​Employee Enrollment Form / Wa​​iver of Coverag​​e - Effective 1/1/2023 (Current)
    • Copy of the current carrier’s most recent billing statement (including all pages).
    • Copy of the most recent quarterly wage report DE-9C​ with all employees listed (including all pages).  Groups with employees residing outside the state of California must provide a QWR from respective states.
    • Completed and signed Participation​ Cert​ific​a​tion form​​ for Employers with 10+ eligible employees.
    • Proof of Ownership Documentation required for all groups enrolling when eligible owners do not appear on DE-9 and DE-9C.
    • United Healthcare quote​​
    • Broker licensing is required at the time of case submission.
    • Husband and Wife groups, owner-only groups and sole proprietors are not eligible.
    • Please NOTE: Tax extensions are not acceptable.


    • ​Corporations:
    • Please NOTE: Provide copy of group’s active status within CA Secretary of State Portal with the group submission.
    • In business < 1 year: S-Corps and C-Corps: Filed Statement of Information that lists all owners/officers’ names.
    • In business > 1 year: S-Corps: IRS Form 1120S (Sc​hedule K-1) for all enrolling owners/officers.
    • C-Corps: I​RS Form 1120 (pages 1 & 2) which includes “Schedule E”.
    • ​Partnership/LLP:
    • Please NOTE: Provide copy of group’s active status within CA Secretary of State Portal with the group submission.
    • In business < 1 year: Partnership Agreement signed by all partners.
    • In business > 1 year: LLC IRS Schedule K-1 Form 1065​ for all partners.
    • LLC:
    • Please NOTE: Provide copy of group’s active status within CA Secretary of State Portal with the group submission.
    • In business < 1 year: LLC Agreement signed by all managers/members/parties.
    • In business > 1 year: LLC Agreement signed by all managers/members/parties or copies of appropriate tax returns (follow the guidelines for an S-Corp, Partnership or Sole Proprietorship based on how the LLC was formed).
    • Sole Proprietorship:
    • In business < 1 year: Business License listing the owner’s name.
    • In business > 1 year: IRS Schedule C (Form 1040).
    • Forms:
    • IRS Schedule F (Form 1040).
    • Broker Licensing: Completed Agent / Agency Agreement​.

    UnitedHealthcare and affiliates reserve the right to request proof of ownership, additional payroll or supporting tax documentation on any submission.
    Groups consisting of Union/Non-Union employees must also provide a copy of their union bill.
    When a company has a DBA (Doing Business ​As), a copy of the Fictitious Business Name Statement must be provided to link the legal name to the DBA.

    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.​
    Important Reminder:  To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website.  For the most recent information regarding UHC’s SBCs, please go to the SBC Page​ or contact your Word & Brown Representative.​