Group Submission Forms

The following is a list of the forms you'll need to enroll a Funding Advantage case for either 12 and under lives OR 12 and over lives. The form for Cost Saver and MEC applies to both 12 and over and 12 and under lives. Feel free to call Sales Support at 888-767-7133 if you have any questions.

Allied National Enrollment

We also accept these online enrollment applications:

FormFire EasyAppsOnline eHealthApp EaseCentral

Call us at 888-767-7133 or email [email protected]

Group Census for New Business 2 to 11 Lives

Group Census for 12+ Lives

Funding Advantage Enrollment Form for 12+

Plan Sponsor Statement
(Employer Form)

Individual Health Question Enrollment Form for Employees

Download this spreadsheet to collect a census for new groups under 12 lives.

Download this spreadsheet to collect a census for new groups of 12 or more lives.

Enrollment form for new groups of 12 or more lives.

Agreement form for an employer to sign indicating willingness to fund a health benefit plan for the company's employees.

Use this medical enrollment form for all major medical groups.

Non-Medical Plan Employee Enrollment Form (for use with MEC, Cost Saver)

This is the non-medical enrollment form for employees enrolling in the Preventive Minimum Essential Coverage (MEC) and Cost Saver ONLY.

Employee/Dependent Waiver (used for all Allied health plans)

Employee Enrollment Recertification

Health History Questionnaires

Used by employees opting out of coverage for themselves or dependents.

Use this form to re-certify "stale" dated enrollment forms.

Use this questionnaire to gather information about an employee's health history.

Sales Transmittal Form

This form must be filled out by the agent or broker and sent in with each case submitted to Allied National.

Freedom Plan Disclosure

Hybrid Freedom Plan Disclosure

Detailed information about our Freedom Plan options and an agreement for employers who have chosen to use the plan.

Detailed information about our Freedom Hybrid Plan options and an agreement for employers who have chosen to use the plan.

Spanish Forms and Flyers

Formulario De Inscripción Para El Plan De Salud Autofinanciado Por El Empleado
(Employee Enrollment Card)

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.

Para el plan de cobertura esencial mínima SOLAMENTE (Employee PMEC
Non-Medical Enrollment Card)

Spanish version of the non-medical enrollment form for employees enrolling in the Preventive Minimum Essential Coverage (PMEC) and Cost Saver ONLY.

Para Inscripciones Medicas D 50+ Solamente (Employee 50+ Enrollment Card)

Spanish version of the Employee 50+ Enrollment Card.

No Cobertura para Empleados y/o Dependientes (Employee / Dependent Waiver)

Spanish version of Employee/Dependent Waiver used by employees opting out of coverage for themselves or dependents.

Recertificación de inscripción de Allied National (Employee Enrollment Recertification)

Spanish version of the Employee Enrollment Recertification.

Looking for Additional Information?

Download brochures, applications, and other resources for all Allied National plans. Use these materials to present plan options to your clients.