Employer Group Enrollment Form For Societies - Ahrens Bar
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1Employer Group Enrollment Form for Societies
Group Administrator Name _________________________________________________________________________
Member Group Name ______________________________________________________________________________
Member Physical Address __________________________________________________________________________
Member Mailing Address ___________________________________________________________________________
Member Telephone _______________________________ Contact Person __________________________________
Employer Federal ID No. if applicable ___________________Member of Group since ___/___/___
The following requirements apply: The purpose of this documentation is to assure the group has a legitimate existence, and
was not formed solely for the purpose of seeking insurance.
To be eligible for enrollment, the following requirements must be met. The applicant must:
1.
Submit their membership information above to attest to active membership within the Group.
2.
If a member has an employee requesting insurance, a NYS-45 ATT must be submitted to substantiate their active
employment.
3.
The group administrator must attest that members are current and up to date on their dues. The appropriate
documentation must be attached to this submission. All paperwork, including applications, must be received by the
th
15
of the month prior to the effective date.
Groups with NYS-45 ATT - please check all appropriate boxes
I am enclosing the most recent Schedule C and/or NYS-45 ATT for my business.
.
All of my covered employees are listed on the NYS-45 ATT
These newly hired employees will be listed on my next NYS-45 ATT. I am enclosing copies of these employees’
2 most recent paystubs.
Name ___________________________________ Name ____________________________
One or more of my covered employees are not listed on the NYS-45 ATT. If retired or on COBRA enter the
month and year of retirement or COBRA. Enclosed is a copy of the last NYS-45 ATT on which the retiree or
employee on COBRA appeared. Please list owners name(s) not appearing on the NYS-45 ATT and submit the
appropriate IRS schedule listed below.
Name ___________________________________ Reason ____________________________
Name ___________________________________ Reason ____________________________
Group Administrator Attestation
As the group administrator, I attest that that the member listed above maintains active and up to date Membership
with our group, meeting all of our requirements, and is current with membership dues.
Name _____________________________________
Date____________________
By signing below the group certifies that they meet the eligibility requirements to be enrolled. I certify that the above
information is true and accurate to the best of my knowledge. I understand that enrollment is subject to BlueCross BlueShield
of Western New York underwriting guidelines and the Group Health Care contract between the Society and BlueCross
BlueShield. I understand that BlueCross BlueShield will conduct annual audits to ensure compliance with these guidelines,
which may require us to provide verification of our being a legitimate member of the Group.
________________________________________________________________
_____________________
Member’s Signature
Date
Revised 10/2/2015
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