RESOURCE CENTER

Client Service Forms
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Member Level Census Template
Beginning 6/1/16, UHC will require member level data (employees and dependents) including first name, last name, date of birth, and home zip code for any all saver quotes for groups with 20+ enrolled. This is the suggested census template.
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2014 Employee Enrollment Form (2-99)
Employee enrollment form to be completed by all enrollment in group health, dental, vision and life products. Form doubles as waiver.
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2014 Employer Application for Small Business (2-99)
UHC branded installation form to be completed by employer for new 2-99 eligible business.
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08.17.2012
Employee Enrollment Form (51-99)
Employee enrollment form to be completed by all enrollment in group health, dental, vision and life products. Medical enrollment does not need to have completed the health questionnaire. Form doubles as waiver.
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02.09.2012
Employee Enrollment Form (2-50)
Employee enrollment form to be completed by all enrollment in group health, dental, vision and life products. Medical enrollment must complete the health questionnaire. Form doubles as waiver.
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11.16.2011
Disabled Dependent Enrollment form
UHC branded form to be completed by Employee, Employer and Physician, requesting a disabled dependent be allowed to continue as a dependent when the dependent has technically exceeded the age limitations of the plan.
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11.16.2011
HRA Benefit Form
UHC branded form to be completed by Employer, when they are funding an HRA account for their employees. This form is how they elect how the plan will distribute funds, how much per employee, and if rollover.
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11.16.2011
Employee Enrollment for additional Dependents (2-99)
Addendum employee enrollment form for those who need to add additional dependents. This is not substitute for the normal Employee Enrollment Form.
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11.16.2011
Employer eServices Form
Form to be completed by the employer to grant themselves or the broker access to Employer eServices. Through Employer eServices, you can access a client's billing and enrollment, including adds, terms, and deletes.
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