Forms

Aetna
Group Application - New business form for corporations
Employee Application - For new enrollee, changing status, add dependents or terminate coverage
Rx Home Delivery - Begin home delivery of maintenance prescriptions
Vision Claim Form - Reimbursement form for eyeglasses, frames and contacts

Capital Blue Cross
Employee Application - For new enrollee, changing status, add dependents or terminate coverage
Employee Waiver Form - For employees choosing to decline coverage offered
Plus Billing Form - Use when submitting employee changes or terminations

Health America / Health Assurance
Group Application - New business form for corporations
Employee Application - For new enrollee, changing status or add dependents
Termination Report - Complete and return to Penn Rise Benefits to terminate employees
Online Account Access - Provides online access for employers to self-manage enrollment changes

Independence Blue Cross - Personal Choice / Keystone
Universal Enrollment - For new enrollee, changing status, add dependents or terminate coverage

United Concordia Dental
Enrollment Form - For new enrollee, changing status, add dependents or terminate coverage

Delta Dental
Enrollment Form - For new enrollee, changing status, add dependents or terminate coverage