New Group Paperwork

Required paperwork

Commercial

• New Group ApplicationOpen a PDF
  • InstructionsOpen a PDF
  • New Group ChecklistOpen a PDF
• Signed rate sheets and benefit selections
• Enrollment forms
• NYS-45 or other state equivalents from the most recently filed report
• For a new employee, a current payroll report and W-4s

Healthy NY

• Healthy NY New Group ApplicationOpen a PDF
  • InstructionsOpen a PDF
  • Healthy NY New Group ChecklistOpen a PDF
  • Healthy NY Eligibility Policy FormOpen a PDF
• Signed rate sheets and benefit selections
• Enrollment forms
• NYS-45 or other state equivalents from the most recently filed report
• For a new employee, a current payroll report and W-4s

Medicare

• Medicare Group Information FormOpen a PDF
  • InstructionsOpen a PDF
• Signed rate sheet
• Enrollment applications
• Medicare Eligibility FormOpen a PDF

If applicable

• Business tax filings if three or fewer enrolling or enrolling owner is not on NYS-45
• SS-4 Letter and Operating Agreement or Articles of Organization/Incorporation for a startup company
• (50 or more full-time equivalent employees) 1094-C to be submitted if the group is part of an applicable large employer
• Waiver of Group Coverage for employees who decline enrollmentOpen a PDF
• Dependent Certification (Student Verification) FormOpen a PDF
• Adult Disabled Dependent FormOpen a PDF
• Dependent Age 29 FormOpen a PDF
• Administrator Electronic and Web Enrollment AgreementOpen a PDF
• Community Rated Subgroup ApplicationOpen a PDF

Additional documents

• Medical Commercial Underwriting GuidelinesOpen a PDF
• Dental & Vision Underwriting OverviewOpen a PDF