Group Administration Form - Alliant Health Plans

GROUP ADMINISTRATION FORM

Alliant Health Plans

Group Name: ________________________________________

Date: ________________________________________

1503 N. Tibbs Rd

Dalton, GA 30720

Group Number: _______________________________________

Prepared By: ___________________________________

Phone: (800) 811-4793

Email: ______________________________________________

Phone Number: ________________________________

Fax: (866) 634-8917

Email:

EMPLOYEE INFORMATION

DEPENDENT INFORMATION

Employee name and Member ID

Transaction

Effective/

**Cobra

Transaction

Effective/

**Cobra

Code*

Term Date

Qualifying

Code*

Term Date

Qualifying

***Changes/Term Reason/Remarks

should always be entered.

Dependent Name

Event

Event

(see keys below)

Employee Name

Employee Mbr ID

AM

AM

AM

*Transaction Code Key:

**Cobra Qualifying Event Key:

1 = Termination of employment

N = New enrollment or dependent addition (requires a signed, fully-

Please sign attesting that this information

completed enrollment form)

2 = Voluntary resignation

has been verified by the employer.

T = Termination of employment (effective date is last day of coverage)

3 = Reduction of hours

C = Change (describe change in remarks section)

4 = Divorce

D = Active employee chooses to drop coverage (includes Medicare)

5 = Ineligible dependent child

Company Official

***Changes: Please provide new information for the following types of changes: PCP, address, phone and other coverage.

NOTE: The addition of dependents due to a Qualifying Event (marriage, divorce, birth, loss of previous coverage) requires supporting documents such as marriage certificate or

divorce decree. Please provide name and phone number of prior employer for enrollment due to loss of employment.

Enrollments must be submitted within 31 days of the date of the Qualifying Event. If Alliant does not administer federal COBRA, the employer is responsible for initiating the

coverage offer.

Please do not mail this form with your premium payment nor adjust your invoice “Total Payment Due” amount. Adjustments for the changes you submit will be reflected on

the next Billing Statement. Allow 3–5 days for processing. For assistance, call 800-811-4793.

Fax completed Group Administration Form to 866-634-8917 or email to .

We will acknowledge receipt of this form. If you do not receive confirmation of receipt within 2 business days, please notify us at .

AHP - GROUP ADMIN FORM

OCTOBER 2015