| Form | EXCLUDING PG & Montgomery Counties | ONLY PG & Montgomery Counties |
|---|---|---|
| Contract and Benefits Booklet Request Form | CUT6592 | CUT6592 |
| Full-Time Equivalent (FTE) Group Size Calculation Worksheet | FRM6237 | FRM6237 |
| Medicare Secondary Payer (MSP) Calculation Form | FRM4011 | FRM4011 |
| Enrollment Transaction Report (ETR) | CUT5796 | CUT5795 |
| Waiver of Enrollment | CUT6529 | CUT6529 |
| Confirmation of Enrollment | CUT5802 | CUT5801 |
| Disability Certification for Overaged Dependent | CUT5625 | CUT5625 |
| Primary Caretaker Certification | N/A | N/A |
| COBRA Continuation | CUT5870 | CUT5861 |
| Selection Form for Continuation of Group Coverage | CUT5862 | CUT5872 |
| Group Screening Questionnaire (51+ Groups) | CUT5486 | CUT5486 |
| Proof of Prior Group Dental Coverage for Voluntary Dental | SUM1750 | SUM1750 |
| Affiliated Companies/Common Ownership Certification | CUT9069 | CUT9069 |
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.
BluePreferred - Miscellaneous Forms - Maryland
Miscellaneous Forms - Maryland