New Group Paperwork
Required
Commercial:
- New Group ApplicationOpen 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-4’s
Healthy NY:
- Healthy NY New Group ApplicationOpen 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-4’s
Medicare:
- Medicare Group Information FormOpen 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
- 1094-C if the group is part of an applicable large employer with 50 or more full-time equivalent employees
- 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
Additional Documents
Required
Commercial:
- New Group ApplicationOpen a PDF
- Signed rate sheets and benefit selections
- Enrollment Applications
- COBRA Administrative AgreementOpen a PDF
Medicare:
- Medicare Annual Group Information FormOpen a PDF
- Medicare Signed rate sheet
- Medicare Enrollment Applications
- Medicare Eligibility FormOpen a PDF
If Applicable
- Name of FSA Administrator
- Certificate of Coverage Run List (Previous Carrier)
- Stop Loss Paperwork
- STM Grids for New Products
- Dependent Certification (Student Verification) FormOpen a PDF
- Adult Disabled Dependent FormOpen a PDF
- Dependent Age 29 FormOpen a PDF
