- Current carrier renewal rates for Medical
- Attach copy of renewal proposal
- Current census
- Relationship
(Column C)
- First and Last name
(Column E & D)
- Gender
(Column G)
- Employee and dependents' dates of birth
(Column H)
- Employee Zip Codes
(Column P)
|
- Last carrier bill
- Copy of all pages of last bill from
current carrier
- New member enrollment applications
- Applications for all eligible employees
not listed in the current carrier bill
- Specialty benefits information
- Attach current specialty benefit plans and
a copy of the specialty benefits renewal
proposal
- Current renewal proposal
|
