Providing Insurance Solutions Since 1979
145 Columbus Road, Suite 201
Athens, Ohio 45701
1-800-333-5394
(740) 589-2900 phone
(740) 593-7388 fax

Downloadable Forms

Aetna

Group

Aetna 2-100 Employer Application & Joinder Agreement
Aetna 2-100 Employee Enrollment Form
Dental Claim Form
Medical Claim Form

Anthem

Group

Employee Enrollment Form 2-50
Employee Termination Form
Anthem Employee Change Form
Employee Enrollment Form 51+
Billing Guide
Anthem Common Ownership Form
EFT Form
Anthem Prescription Mail Order Form
Medical Claim Form
Anthem Sold Case Checklist
Employer 2-50 Enrollment Form
HSA Customer Agreement Form

Individual

Anthem Coreshare Brochure
Anthem Lumenos Plus Brochure
OH Anthem Individual App 8.11
Anthem Ind Change of Coverage

Individual Questionnaires

Abnormal Pap Smear
Alcohol/Drug
Arthritis
Asthma/Allergy
Attention Deficit Disorder
Back/Spinal
Colitis/Irritable Bowel Syndrome
Diabetes
Digestive
Ear/Otitis
Endometriosis
Fibromyalgia
Gout
Heart Murmur/Mitral Valve Prolapse
Hypertension
Kidney/Urinary
Mental Health
Migraine
Seizure/Epilepsy
Thyroid
Tumor/Cyst/Skin Cancer
Ulcer

Companion Life

10+ True Group

10+ Employee Application
10+ Employee Health Statement
10+ Employer Application

2-9 Trust

2-9 Employee Application
2-9 Employee Health Statement
2-9 Employer Application

Claims

Companion Life Short Term Disability
Companion Long Term Disability Form
Companion Life Dental Claim Form
Companion Life Claim Form

CRL

Group

Certification of Employer
Employee 2-50 Enrollment Form
Employee 51+ Enrollment Form
Prescription Drug Claim Form
Employee Change Form
Partnership Employee Enrollment Form
Employer Application for Reinstatement
Prescription Mail Order Form

Individual

Guardian Life

Group

Guardian Non Medical Employer Application
Guardian New Case Submission Requirements
Guardian Multi Line EE Enrollment Form

Humana

Group

Employee Change Form rev11.06
Employee Application 2-50
Employer Application
Humana Right Source Mail Order Form
Prescription Drug Prior Authorization Form

Individual

MHM POP 125

Group

MHM POP Brochure App 6-08 FILLABLE.pdf

Principal

Employer Sponsored
Voluntary

Southeastern Agency

Forms

Group Quote Request
Individual Quote Request Form
Prescription Cost Management Program

United HealthCare

Group

OH Small Business Benefit Option Checklist
UHC Employer 2-99 Application
UHC Employee 2-9 Enrollment Form
UHC Common Ownership Form 2-50
UHC EFT Form
UHC Sold Case Checklist 2-50
UHC Employee 10-50 Enrollment Form
UHC Employee 51-99 Enrollment Form

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