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

Anthem

Group

Billing Guide
EFT Form
Employer Application 2-50
Wellpoint Prescription Mail Order Form
Medical Claim Form
Wellpoint Prescription Claim Form
Employee Termination Form
Employee Enrollment Form 2-50
Employee Change Form
Employee Enrollment Form 51+
Anthem Formulary Drug List 2008

Individual

Lumenos HIA Brochure
Lumenos HIA+ Brochure
Lumenos HSA Brochure
Attained Age Medicare Supplement Brochure
Blue Access Brochure
Blue Access Economy Brochure
Blue Access Value Brochure
Dental Brochure
Downgrade Policy Change Form
Healthy Lifestyle Questionnaire
HIPPA Application
HIPPA Brochure
HIPPA Open Enrollment Form
HIPPA Rates
Issue Age Medicare Supplement Brochure
Life Insurance Brochure
Attained Age Application
Issue Age Application
Short Term Application and Brochure
HSA Lumenos Plan Benefits Guide
HIA Lumenos Plan Benefits Guide
HIA+ Lumenos Plan Benefits Guide
Mail Order Form
Formulary Drug List rev9.06
Blue Access Plan Benefit Guide
Anthem Enrollment Application 6-07.pdf

Individual Questionnaires

Abnormal Pap
Alcohol & Drug
Arthritis
Asthma & Allergy
Attention Deficit
Colotis-Irritable Bowel
Diabetes
Digestive
Ear-Otitis
Endometriosis
Fibromyalgia
Gout
Hypertension
Kidney-Urinary
Mental Health
Migraine
Seizure-Epilepsy
Spinal
Thyroid
Tumor-Cyst-Cancer
Ulcer

United HealthCare

Group

UHC Formulary 2008
Employee 2-9 Enrollment Form
Employee 10-50 Enrollment Form
Employer Enrollment Form 2-99
Employee Enrollment Form 51-99

Aetna

Group

Medical Claim Form
Dental Claim Form
2-50 Employee Application
2-50 Employer Application
Health Questionnaire
Aetna 2008 Formulary Guide
Aetna 2008 Formulary Update

Humana

Group

Employee Change Form rev11.06
Humana Right Source Mail Order Form
Prescription Drug List 3 Tier
Prescription Drug Prior Authorization Form
2-9 Employee Application
10-50 Employee Application

Individual

Medical Mutual

Individual

Individual Application & Change Form
Healthy Lifestyle Questionnaire
SuperMed One Sales Kit
First Horizon HSA Account Application
Medicare Supplement Brochure and Rates
Medicare Supplement Application
Short Term Brochure and Application
Vision Benefits
Dental Benefits
Prescription Drug Claim Form
Prescription Drug Guide 2007 Rev 6.07
Wells Fargo HSA Account Application
Prescription Mail Order Form

Group

MMO 1-99 Employer Application rev2.08
Prescription Drug Claim Form
Member Claims Appeal Form
Deductible Credit Carryover Form
Medical Claim Form
Application for Continuation of Coverage for Physically Handicapped Dependent
Student Certification Form
Administrative Kit
Underwriting Exception Request Form2
MMO 1-19 Employee Application rev1.08
Medco Prescription Mail Order Form
MMO 2007 Formulary Guide
MMO 20+ Employee Application rev1.08

Companion Life

2-9 Trust

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

10+ True Group

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

Southeastern Agency

Forms

2-50 Generic Application
Individual Quote Request
Group Quote Request
Prescription Cost Management Program

CRL

Group

CRL Prescription Formulary 2008
Prescription Drug Claim Form
Certification of Employer
Employer Application for Reinstatement
Prescription Mail Order Form
Employee 2-50 Enrollment Form
Employee 51+ Enrollment Form
Partnership Employee Enrollment Form
Employee Change Form

Individual

Elite Advantage Brochure
Grin and Share It Individual Dental
Dental Application
Dental Rate Guide
Savers Advantage Brochure.pdf
Benefit Design Rate Request Form
HSA Advantage Plus
Select Advantage Brochure

Principal

Voluntary
Employer Sponsored

MHM POP 125

Group

MHM POP 125 Application

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