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Frequently Requested Forms

Stafford Insurance Anthem Provider indiana

2-50 Employee Application: For Employees (Groups with 2-50 employees)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage
51+ Employee Application: For Employees (Groups with 51 or more employees)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage
Employee Change Form: For Employees (Regardless of Group Size)
Use for ie) address & name changes, deleting a dependent, life beneficiary changes, or if employee is waiving coverage
2-50 Employer Application: For Employers with 2-50 employees
Employers should use when applying for new coverage through Anthem.

51-99 Employer Application: For Employers with 51-99 employees
Employers should use when applying for new coverage through Anthem.

Individual Application:  For Individuals  (non-group coverage)
Use for applying for new coverage, changing existing coverage, adding dependents

Short-Term Application: For Individuals (non-group coverage)
Use for applying for new coverage - 6 months or less

Anthem Fact Sheet:
Quick Facts and Figures about Anthem Blue Cross & Blue Shield.


 2-9 Employee Application: For Employees (Groups with 2-9 employees)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage.

 10-50 Employee Application: For Employees (Groups with 10-50 employees)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage.

 51-99 Employee Application: For Employees (Groups with 51-99 employees)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage.

 2-99 Employer Application: For Employers with 2-99 employees
Employers should use when applying for new coverage through United.



Grange Life - $en¢ible Benefits Application
For Employees applying for Voluntary Group Life Insurance.
Grange Life - $5,000 to $99,999 Application
For Individuals applying for $5,000 to $99,999 of Life Insurance.
Grange Life - $100,000+ Application
For Individuals applying for $100,000 or more of Life Insurance.
Grange Life - $en¢ible Benefits Term Life Rates
Current rates for Male/Female, Smoker/Non-Smoker Term Life Insurance for Employees applying for Voluntary Group Life Insurance.

 

Principal

Employee Application: For Employees (any size group)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage

Employer Application: For Employers with 2 or more employees
Employers should use when applying for new coverage through Principal.
Employer Eservice Set Up Form: Qualification for Employers
Employer Morbid Obesity Rider Form: Rejection/Election of Obesity Rider for Employers

 

 Stafford Insurance Consumer Life Partner Indiana

Employee Application: For Employees (Groups with 2-19 employees)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage

Employee Application: For Employees (Groups with 20+ employees)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage

Employer Application: For Employers with 2 or more employees
Employers should use when applying for new coverage through Consumers Life
Group Contract:  Contract for Employers
Stafford-Insurance-American-Community-Provider

Employee Application: For Employees (any size group)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage

HIPPA form: Employee Consent/Agreement

Employer Application: For Employers (any size group)
Employers should use when applying for new coverage with American Community

Request to participate: Participation form for Employers


 Stafford Insurance Metlife Provider Indiana

2-9 Employee Application: For Employees (Groups with 2-9 employees)
Use for New Employees, adding a new dependent, COBRA, or if employee is waiving coverage

10+ Employee Application: For Employees (Groups with 10 or more employees)
Use for New Employees, adding a new dependent, COBRA, of if employee is waiving coverage

Employer Application: For all employers
Employers should use when applying for new coverage with MetLife