RESOURCE CENTER

Installation Forms
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ELF Spreadsheet template (for 51+ Mid-Size new business)
Requires a 51+ quote AND at least 30+ enrolled. This excel file must be completed in full and can replace the need for paper application submission. No other file will be accepted.
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2017 Application for 51-99 Mid-Size Employer Coverage
IBC branded installation form to be completed by employer for new 51-99 eligible business. Includes new plan designes for 2017.
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2017 Renewal & Savings Forms (2-50 size)
IBC branded renewal form to be completed by employer for existing 2-50 eligible business. For employers making changes to the 2017 Metallic Blue Solutions products.
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2017 Employee (2-50 size) Enrollment/Change form
Employee enrollment/change form to be used by someone who wishes to enroll into an IBC metallic tier plan, beginning with 1/1/17. Application can also be used to add/delete dependents, or change benefits. Also applies to group Medigap enrollments.
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2017 Application for 2-50 Small Employer Coverage
IBC branded installation form to be completed by employer for new 2-50 eligible business. Includes new plan designes for 2017.
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2017 Small Employer Group application for BlueSaver HSA
This application and checklist should be used with employer groups when the broker cannot complete HSA setup through RO AM. New customers and any customers newly selecting a qualified high-deductible health plan can generaly have accounts opened auto
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2017 Small Employer Group application for BlueSaver HRA
The Small/Mid-Size Group HRA is a notional account which does not require any pre-funding. Please make sure you review the Spending Account Invoicing Guide to become familiar with the claims invoicing process which the employer can manage through the
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2016 Renewal & Savings Forms (Blue Solutions)
IBC branded renewal form to be completed by employer for existing 2-50 eligible business. For employers making changes to the 2016 Metallic Blue Solutions products.
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2016 Employee (2-50 size) Enrollment/Change form
Employee enrollment/change form to be used by someone who wishes to enroll into an IBC metallic tier plan, beginning with 1/1/16. Application can also be used to add/delete dependents, or change benefits. Also applies to group Medigap enrollments.
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2016 Application for 2-50 Small Employer Health Benefits (released 10/2015)
IBC branded installation form to be completed by employer for new 2-50 eligible business. Includes new plan designes for 2016. Can also be used for Blue Choice products (private exchange/defined contribution)
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08.27.2015
Independence/Amerihealth NJ (IBC/AHNJ) BOR letter
Sample of Broker of Record letter to be used for existing IBC or AHNJ clients. No other version will be acceptable.
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2015 Employee (2-50 size) Enrollment/Change form
Employee enrollment/change form to be used by someone who wishes to enroll into an IBC metallic tier plan, beginning with 1/1/15. Application can also be used to add/delete dependents, or change benefits. Also applies to group Medigap enrollments.
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2015 Application for 2-50 Small Employer Health Benefits (released 12/2014)
IBC branded installation form to be completed by employer for new 2-50 eligible business. Includes new plan designes for 2015. Can also be used for Blue Choice products (private exchange/defined contribution)
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Waiver of Coverage Form
To be completed by an eligible employee waiving coverage. Only acceptable waivers of coverage are: spousal coverage, Medicare/Medicaid, Federal coverage, and Dependent on parent plan. Exchange coverage is not valid waiver.
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2015 Renewal & Savings Forms (Blue Solutions)
IBC branded renewal form to be completed by employer for existing 2-50 eligible business. For employers making changes to the 2015 Metallic Blue Solutions products.
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