RESOURCE CENTER

Installation Forms
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2017 Plan Change Form (GROUP)
2017 form which employer must complete for NEW setup and change their existing Group sponsored Medicare Advantage plan. This form is for new and renewal submissions for 1/1/17 and is due by 10/15/16.
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2016 Keystone 65 (GROUP) Employee application
2016 Application employee or retiree must complete to enroll in a Group sponsored Keystone 65 plan. Employer Plan Change Form (with rates) are also required and both should be sent to Brown & Brown 30 days in advance of effective date.
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2016 PPO 65 (GROUP) Employee application
2016 Application employee or retiree must complete to enroll in a Group sponsored Personal Choice 65 plan. Employer Plan Change Form (with rates) are also required and both should be sent to Brown & Brown 30 days in advance of effective date.
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2016 Select Option PDP (GROUP) Employee application
2016 Application employee or retiree must complete to enroll in a Group sponsored Select Option PDP plan. ONLY RETIREES MAY ENROLL. Plan Change Form (with rates) are also required and both should be sent to B&B 30 days in advance of effective date.
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2016 Medigap Security (GROUP) Employee application
2016 Application employee or retiree must complete to enroll in a Group sponsored Medigap Security plan. Employer Plan Change Form (with rates) are also required and both should be sent to Brown & Brown 30 days in advance of effective date.
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2016 Plan Change Form (GROUP)
2016 form which employer must complete for NEW setup and change their existing Group sponsored Medicare Advantage plan. This form is for new and renewal submissions for 1/1/16 and is due by 10/18/16.
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Tips Completing a Paper Application
For paper applications, you should be sure to check with your upline for submission guidelines. Make sure the paper applications are complete and free of errors in order to avoid processing delays.
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2015 Plan Change Form (GROUP)
2015 form which employer must complete to change their existing Group sponsored Medicare Advantage plan. This form is only for renewal changes for 1/1/15 and is due by 10/15/14.
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2014 Keystone 65 (GROUP) Employee application
2014 Application employee or retiree must complete to enroll in a Group sponsored Keystone 65 plan. Group rates are also required and both should be sent to your account manager 30 days in advance of effective date.
email download
2014 PPO 65 (GROUP) Employee application
2014 Application employee or retiree must complete to enroll in a Group sponsored Personal Choice 65 plan. Group rates are also required and both should be sent to your account manager 30 days in advance of effective date.
email download
2014 Select Option PDP (GROUP) Employee application
2014 Application retiree must complete to enroll in a Group sponsored PDP plan. ONLY RETIREES MAY ENROLL. Group rates are also required and both should be sent to your account manager 30 days in advance of effective date.
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2014 Medigap Security (GROUP) Employee application
2014 Application employee or retiree must complete to enroll in a Group sponsored Medigap Security plan. Group rates are also required and both should be sent to your account manager 30 days in advance of effective date.
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2014 Select Option Plan Change Form (GROUP)
2014 form which employer must complete to change their existing Group sponsored Select Option PDP plan. This form is only for renewal changes for 1/1/14 and is due by 11/15/13.
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New Business Submission Guide (INDIVIDUAL)
This guide is for Amerihealth New Jersey and Independence Blue Cross INDIVIDUAL Medicare Advantage applications ONLY
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2014 New Business Cover Sheet - online application (INDIVIDUAL)
This form is required with every Individual Medicare Advantage IBC/AHNJ online application submitted through our office.
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