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Client Service Forms
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2017 Small Employer Waiver of Coverage (SEH)
For all 2017 business, the following updated small group applications must be used or the group will be rejected by Horizon's compliance department. Waiver form for new business and conversions.
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2017 Small Employer Certification form (SEH)
For all 2017 business, the following updated small group applications must be used or the group will be rejected by Horizon's compliance department. Required for new business and annually prior to group's annievrsary.
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07.01.2015
Small Employer Employee Application (SEH)
Horizon branded Employee enrollment form needed for new business or existing member changes/terminations. Also used for NJ HINT - Dependent to 31 enrollments.
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01.30.2013
Conversion (Renewal) Form
Horizon branded form to be submitted with any renewal request where employer is looking to change benefits, or migrate members from one sub-group to another. Must be submitted with desired renewal quote option.
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12.05.2012
Horizon 2013 Cutoff Dates
Listing of possible effective dates for all of 2013 for new business and conversion business, and their respective cutoff dates. Please be advised Horizon will hold firm to these dates, as exceptions are rarely granted.
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10.26.2012
MA Reform Law - Minimum Coverage Level Attestation Form
Massachusetts reform law requires all adult residents have a minimum level of creditable health insurance. Carriers are required to provide a 1099-HC form to MA residents. Affected members MUST complete & return attestation form by 11/1/12.
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05.30.2012
Dependent to 30 HINT application (Florida)
Form to be completed by the member and dependent, if they wish to enroll a FL residing child who is up to age 30 with Horizon. Specific rules apply, so please check before having completed. Send completed paperwork to your Account Manager.
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05.08.2012
Horizon 2012 Cutoff Dates
Listing of possible effective dates for all of 2012 for new business and conversion business, and their respective cutoff dates. Please be advised Horizon will hold firm to these dates, as exceptions are rarely granted.
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03.29.2012
HINT Q&A - NJ Dependent to 31 law
Q&A regarding the NJ law, requirements, how to enroll, etc.
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03.29.2012
HINT information - NJ Dependent to 31 law
General information regarding the NJ law, requirements, how to enroll, etc.
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02.15.2012
Horizon 2Q 2012 Cutoff Dates
Listing of possible effective dates thru 2Q 2012 for new business and conversion business, and their respective cutoff dates. Please be advised Horizon will hold firm to these dates, as exceptions are rarely granted.
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01.06.2012
Eligibility Rules
Comprehensive listing of eligibility rules for Horizon BCBS of NJ. This file includes benefit waiting period definitions, new hire vs rehire rules, employees on termporary leave, termination scenarios, and more...
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12.14.2011
Horizon 1Q 2012 Cutoff Dates
Listing of possible effective dates in 1Q 2012 for new business and conversion business, and their respective cutoff dates. Please be advised Horizon will hold firm to these dates, as exceptions are rarely granted.
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03.23.2011
Auto Pay Application form (SEH)
Horizon branded form needed if group wishes to sign up for automatic debit withdrawl for premium payments
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03.23.2011
Small Employer Waiver form (SEH)
Horizon branded Waiver form for new business and conversions
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