BluePreferred - Miscellaneous Forms - District of Columbia

Miscellaneous Forms - District of Columbia

FormDC
Contract and Benefits Booklet Request Form CUT6592
Full-Time Equivalent (FTE) Group Size Calculation Worksheet FRM6237
Medicare Secondary Payer (MSP) Calculation Form FRM4011
Enrollment Transaction Report (ETR) CUT5795
Waiver of Enrollment CUT6529
Confirmation of Enrollment CUT5801
Disability Certification for Overaged Dependent CUT5625
Primary Caretaker Certification CUT5858
COBRA Continuation EOD5004
Selection Form for Continuation of Group Coverage EOD5001
Group Screening Questionnaire (51+ Groups) CUT9040
Proof of Prior Group Dental Coverage for Voluntary Dental SUM1750
Affiliated Companies/Common Ownership Certification CUT9069
GHMSI—DC Stop Loss Application (Self-Funded Underlying Medical Product) DC/GHMSI/SL APP (R. 6/15)
DC Stop Loss Disclosure DC/GHMSI/SL DISC (9/15)