Fixed Funding Solutions
Forms, Documents & Enrollment Materials

For companies with 51 or more eligible employees

For Employers

• CBIA Membership Application
• Participation and Contribution Guidelines
• Group Installation Checklist
• Underwriting Guidelines
• Underwriting Rules and Disclaimers
• Employer Participation Agreement - includes New York Public Goods Forms
  (for groups effective or renewing January 2023 and beyond)
• Stop Loss Application
• Enrollment Statement (for owners not appearing on UC5a)
• Direct Debit Form
• Authorization for Electronic Payment Form
• Registration for Online Account Access
• Important Tax Information for Self-funded Plan Participants
• HealthEquity HRA/HSA Setup

For Employees

• Enrollment/Change Form
  (for groups effective or renewing January 2024 and beyond)
• Enrollment/Change Form
  (for groups effective or renewing January 2023 through December 2023)
• Enrollment/Change Form
  (for groups effective or renewing July 2021 through December 2022)
• Individual Medical Questionnaire Printable Form
  (may be requested for enrollees not previously underwritten)
• Individual Medical Questionnaire Digital Form
  (may be requested for enrollees not previously underwritten)
• Waiver of Coverage Form
• Domestic Partner Affidavit
• Domestic Partner Termination
• Mail Order Prescription Form
• Prescription Reimbursement Claim Form
• Out of Network Reimbursement Form
• Application for Continuation of Coverage for a Disabled Dependent Child
• Authorization to Use or Disclose Protected Health Information
• Language and Non-Discrimination Notice

Life & Disability forms

• Life & Disability forms

Dental forms

• Dental forms