RESOURCE CENTER

Installation Forms
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03.07.2012
Employer Application (for PA group coverage 2-100 eligible - eff 5-1-12)
Aetna branded installation form to be completed by employer for new PA situs 2-100 size business. This form MUST be used for 5/1/12 effective dates and forward. Old applications will no longer be accepted.
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03.07.2012
Employee Enrollment/Change Form (2-100 Eligible PA Employees - eff 5-1-12)
Employee enrollment form for PA situs groups groups with 2-100 eligible employees. This app must be used for groups 5/1/12 effective and forward, old apps will not be accepted.
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01.17.2012
Aetna - 2012 new business deadlines (NE region)
Listing of Aetna new business submission deadlines in calendar form
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12.19.2011
PA Installation Checklist
Aetna branded checklist for new business in PA
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12.19.2011
Pre-screen Underwriting form for PA & DE
Aetna required form for underwriting prescreen for PA or DE sitused groups of 5 or more enrolled. Aetna no longer accepts group questionnaires, use applications for all sizes (Return with appropriate employee forms and quote to your Account Manager)
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09.01.2011
Employer Verification form
Required by Aetna for all new business, so Aetna can report proper employee count to the Federal Government. Groups with 50+ employees reported on a wage & tax form, including those of affiliated companies, must offer certain mandates.
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09.01.2011
Employer Funding Certification for SG plans (PA, DE)
To be completed by all employers offering a plan with a $1000 or greater deductible. Employers cannot fund more than 50% of the deductible through an alternate funding mechanism.
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09.01.2011
Employer Application & Joinder Agreement (for group coverage 2-50)
Aetna branded installation form to be completed by employer for new 2-50 size business
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09.01.2011
Proof of Eligibility form
For small group installation, to be used for eligible individuals that are not reported on a quarterly wage and tax form. For example, Sole Proprietors, Partners, and Corporate Officers; additional paperwork would be required.
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09.01.2011
Employee Enrollment/Change Form (2-50 Eligible Employees - SPANISH)
Employee enrollment form for groups with 2-50 total employees IN SPANISH
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09.01.2011
Associated Companies
Form to be completed by small employers (2-50) with affiliated companies, subsidiaries, or common ownership and are attempting to enroll all companies as 1 group.
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09.01.2011
Employee Enrollment/Change Form (2-50 Eligible Employees)
Employee enrollment form for groups with 2-50 total employees.
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09.01.2011
ACH form - New Business Request
Form to be used with new business, if employer wishes to pay via ACH and not submit a physical check.
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08.01.2011
Employee Count Addendum form (required for new business)
This addendum is required for all new business with less than 200 lives. Due to Health Care Reform, capturing accurate employee count over the last calendar year is required by carriers.
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07.28.2011
Aetna BOR letter
Sample of Broker of Record letter to be used for existing Aetna clients. No other version will be acceptable.
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