Forms & Documents

Medical and dental enrollment forms (101+ full-time equivalent employees)

1. Choose application based on whether the product requires a primary care physician
2. Select the plans your group offers from the dropdown(s) under Medical and Dental Plan Selection

• PPO/EPO/Indemnity - No Primary Care Physician (PCP)Open a PDF
• POS/HMO - Requires Primary Care Physician (PCP)Open a PDF

Additional enrollment forms

• Additional Dependent AddendumOpen a PDF
• Membership Cancellation Worksheet Open a PDF
• Vision Enrollment FormOpen a PDF

Medicare enrollment forms

• Medicare Supplement Enrollment FormOpen a PDF
• Univera HMO / PPO / Medicare Supplement DisenrollmentOpen a PDF
• Enroll, change or cancel coverage for a Medicare Advantage or Medicare Supplemental member

2026 enrollment applications

• Medicare PPO / SeniorChoice HMO-POS Group Enrollment FormOpen a PDF