Application For Group Coverage Form
ADVERTISEMENT
1IDAHO AGC HEALTH PLAN
Application for Group Coverage
Legal Name of Business: __________________________________________ DBA (if applicable):________________________________________
SIC________________ Tax ID Number (TIN) _______________________Type of Business________________________________
Type of Organization:
Corporation ________
Partnership ________ _
Proprietorship ________
Other _________________
Membership in Idaho AGC: General: __________ Specialty: __________ Assoc. Supplier: __________ Assoc. Professional______________
Mailing Address:
____________________________________________City: _____________________________State_________Zip___________
Physical Address: ____________________________________________City: _____________________________State_________Zip___________
Is the business domiciled in the state of Idaho ______YES _____NO Requested effective date of coverage: ____________________
Is this business currently involved in bankruptcy proceedings? ______YES _____NO If yes, please explain: ____________________________
________________________________________________________________________________________________________________________
Contact Information:
Group Administrator___________________________________________________E-mail: _____________________________________________
Phone: _____________________________________________________ Fax: ________________________________________________________
The Idaho AGC Health Plan is a group plan. To qualify as a group an employer must have a minimum of two full-time employees and the company must
be eligible for Idaho AGC Membership.
Total Number of Employees
(all employees, not just those participating on the plan):
Full-Time_______, Part-Time_______, Leased________,Seasonal_______ Union (exempt)_____ (Put each employee in ONE category)
An eligible employee is one that has completed their probationary period and works 30 or more hours per week.
Number of eligible employees in your group: _____________
Total number of employees on health plan:________________
Does the group have any active COBRA participants or terminated employees or dependents of employees still in their initial COBRA election
period? If yes, please list below: (An additional sheet may be used if needed.)
1)______________________________________/_____/___________ 2)_____________________________________________/_____/___________
NAME
EFF DATE OF COBRA
NAME
EFF DATE OF COBRA
3)_____________________________________/_____/____________ 4)_____________________________________________/_____/___________
NAME
EFF DATE OF COBRA
NAME
EFF DATE OF COBRA
Contributions
The Group agrees to make the following employer contribution toward employee and their dependents premium
_________% per employee per month
OR
$____________per employee per month
_________% per dependent per month
$____________per dependent per month
Only employees and their dependents that wish to be covered on the Idaho AGC Health Plan should complete health applications. Any employee
waiving medical coverage must complete a Blue Cross of Idaho waiver. Any changes made to a group’s census after initial rates are released will
require the entire group be re-underwritten by Blue Cross of Idaho, and subject to rate adjustments based on the change.
Commission requested if group is 51+ contracts_____________ (standard is 3%).
BROKER: _______________________________________________
AGENCY:_______________________________________
ACCT REP:______________________________________________
PHONE: ________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal