Form | DC |
---|---|
Contract and Benefits Booklet Request Form | CUT6592 |
Full-Time Equivalent (FTE) Group Size Calculation Worksheet | FRM6237 |
Medicare Secondary Payer (MSP) Calculation Form | FRM4011 |
BlueChoice Point of Service Selection | N/A |
Enrollment Transaction Report (ETR) | CUT5795 |
Waiver of Enrollment | CUT6529 |
Confirmation of Enrollment | CUT5801 |
Disability Certification for Overaged Dependent | CUT5625 |
Primary Caretaker Certification | N/A |
COBRA Continuation | EOD5004 |
Selection Form for Continuation of Group Coverage | EOD5001 |
Group Screening Questionnaire (51+ Groups) | CUT5486 |
Affiliated Companies/Common Ownership Certification | CUT9069 |
Proof of Prior Group Dental Coverage for Voluntary Dental | SUM1750 |
D.C. Risk Groups Employer Request for Religious Accommodations | SUM5049 |
Please be advised, the Broker Portal and Broker Express will undergo maintenance from 3 pm Friday 4/19th to 4 am Monday 4/22nd The applications will be inaccessible during this time.
HealthyBlue - Miscellaneous Forms - District of Columbia
Miscellaneous Forms - District of Columbia