Funding Advantage Form
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Send RFPs to [email protected].
This page provides the administrative forms and resources you need to request a quote, enroll a group and access key employer documents — all in one place.
Looking for sales tools or marketing materials? Visit your Agent Edge page for additional resources. |
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Shortcuts
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Sales Forms
Send RFPs to email [email protected].
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major medical product - Groups of 2-9 LIVeS
COST SAVER
Our Cost Saver plans are guaranteed issue. Click here to download RFP forms (this should link to a zip file with all templates to get a CS quote)...census, er disclosure Firm rates (zip file//// View submission guidelines. Our Minimum Essential Coverage (MEC) plans are guaranteed issue. Click here to download RFP forms. (this should link to a zip file with all templates to get a MEC quote)............rfp only Firm rates (zip file//// -- ask ronna, randy what fill out View submission guidelines here. DENTAL DESIGN
Designed for groups of 2-99, Allied™ Dental Design offers affordable dental insurance benefits and many plan options that allow groups to choose the type of coverage that best fits their needs and budget. Check out our Dental Design Brochure or download our group dental forms. Click here to enroll. Form Fire - EasyAppsOnline - eHealthApp - EaseCentral Call us at 888-767-7133 or email [email protected] |
Underwriting & Enrollment Forms
Here are your materials for enrolling a Funding Advantage case.
Medical Forms
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Use this medical enrollment form for all major medical groups. Agreement form for employers to sign indicating willingness to fund a health benefit plan for the company's employees. The non-medical enrollment form is for employees enrolling in the Preventive Minimum Essential Coverage (MEC) and Cost Saver Plans ONLY. This plan is to be used by employees opting out of coverage for themselves or dependents for all Allied health plans. Use this form to re-certify "stale" dated enrollment forms. User guide for agents and employers to enroll easily online. Follow the steps to completing health plan enrollment forms for both initial enrollment and plan add-ons. This form must be filled out by the agent or broker and sent in with each case submitted to Allied National. This form includes detailed information about our Freedom Plan options and an agreement for employers who have chosen to use the plan. This form includes detailed information about our Freedom Hybrid Plan options and an agreement for employers who have chosen to use the plan. Download this spreadsheet to collect a census for new groups. |
Dental/Vision Forms
Spanish Forms
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Spanish version of a form that each employee needs to fill out and sign; will be turned in to Allied National by the Agent, along with the signed Plan Sponsor Statement. Spanish version of the non-medical enrollment form for employees enrolling in the Preventive Minimum Essential Coverage (MEC) and Cost Saver ONLY. This is the Spanish version of the Employee 50+ Enrollment Card. This is the Spanish version of the Employee/Dependent Waiver used by employees opting out of coverage for themselves or dependents. This is the Spanish version of the Employee Enrollment Recertification. |
Employers Forms
Medical Forms
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Use this form to certify that an employee’s partner is eligible to participate in the health plan as a dependent spouse. This is the form an employee fills out to show their interest in being enrolled in the company's group health benefit plan. A member signs this form to authorize Allied National to have access to their health documents. This form authorizes Allied National to subtract payments from an employer's checking account. Employers need to fill out this spreadsheet listing each employee who is electing coverage. A sample of the monthly report sent to employers showing information such as claims paid and employee participation. Here's a list of the current compliance requirements for employers. This COBRA Guide is intended to assist employers with managing their COBRA obligations as the Plan Administrator (as defined by ERISA). The Premium Only Plan (POP) offers employers and their employees great tax benefits. An employer can offer a tax-favored option to employees and at the same time lower the employer's payroll taxes. Download the Allied National Premium Only Plan Enrollment Data Sheet and Application. Here are the appeal forms a member needs if they are interested in filing a claim appeal. The Allied National appointment system is easy! Simply fill out the appointment forms, print, and then mail, fax or e-mail your completed forms. |
