Forms | Group Benefit Services

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Fully-Insured

Group Application

Enrollment Form

Spanish Employee Election Form (with Addendum)

Small Group Checklist

Small Group Census Template

Confirmation of Full-Time Student Status

Electronic Payment Options

Group Insurance Ineligibility Listing

Small Group Termination Request

Large Group Census Template

Large Group Screening Form

Self-Funded

HealthyAdvantage Checklist

Self-Funding 101

HealthyAdvantage Plan Services Agreement

HealthyAdvantage Cigna Pre-Sale Form

Cigna CWI GBS LifeSource Agreement

Cigna CWI GBS Network Service Agreement

Cigna CWI GBS PBM Agreement

Domestic Partner Affidavit

GBS Health Plans Enrollment Form

GBS Health Plans Late Submission Letter

GBS Health Plans Late Letter to Employees

Medical Claims Form

New York Surcharge Form

Traditional Self-Funded Request for Proposal

Traditional Self-Funded Checklist

Services

HRA Application & ACH Form

HRA Enrollment Form

HRA Premium Reimbursement Form

Premium Reimbursement HRA Group Application

Individual Coverage HRA Group Application

FSA Application & ACH Form

FSA Enrollment Form (All Services)

FSA Enrollment Form (Health & Dependent Care)

FSA Enrollment Form (Health FSA)

FSA Transportation Reimbursement Form

COBRA Administration of Extended Benefits Form

Online Enrollment Agreement

Brokers

General Carrier Transfer

Single Case Amendment BOR