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Forms
Request for Quote Forms
Broker Demographic Change Form
Broker Bonus Networking Form
Broker Bonus Check Exception Form
Lovelace Sales Notification Form
Direct Deposit Enrollment and Authorization Form
Disability Determination Form
Appointment of Personal Representative Form
New Group Submission Forms
New Group Implementation Checklist
Group Master Application
Employee Enrollment/Change Form (English)
Employee Enrollment/Change Form (Spanish)
SCI (State Coverage Insurance) Group Enrollment/Change Form
Waiver Form
ACH Debit Authorization Form (Medical Only)
Employer Late Enrollment Letter
United Concordia Dental Forms
United Concordia Small Group Application for Group Dental Insurance
United Concordia Dental Plan Enrollment/Change Form
OptumHealth COBRA Implementation Forms
OptumHealth Financial Services COBRA Administration
File:
Form_LHP New Group Implementation Checklist_5-17-11.pdf
Form_LHP Group Application 2-15-12.pdf
Enrollment Change English_writeable_6-25-12.pdf
Form_LHP Waiver of health insurance coverage_5-27-10.pdf
Form_New_ACH Withdrawl Auth Form 11-2-11 (2).pdf
Form_New_credit card authorization form Groups.pdf
6 Mos State Cont. Premium Subsidy Summary and Application 051209.pdf
Form_LHP Group Application_10-2-12.pdf
LHP Group Application 2-18-11.pdf
UCCI Small Group Application Writeable 2011.pdf
UCCI Enrollment Form 2011.pdf
Form_DOS Acknowledgement letter.pdf
Form_Lovelace Sales Notification Form.pdf
Enrollment Change Form_Spanish_6-25-12.pdf
LHP_broker demographic change_form_one page_electronic_template_8-18-11.pdf
SCI Group Change Form.pdf
LHP_broker demographic change_form_one page_electronic_template.pdf
SCI Group Enroll-Change Form_Layout 1.pdf
LHP_broker bonus check exception_form_writeable_7-10-12.pdf
DIRECT DEPOSIT_EMDePayContractAuthSingle.pdf
LHP_disability determination form_1-19-12.pdf
LHP_broker networking form_writeable_3-26-12.pdf
LHP New Group Implementation Checklist_10-10-12.pdf
LHP Master Group Application_10-9-12.pdf
LHP_UG_ACH Withdrawl_NEW_10-5-12.pdf
Emdeon_ePaymentEnrollment.pdf
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