Looking for a Document or Need More Information?
We know that the more quotes you put out there, the more productive you’ll be. So to save you time and money, we’ve developed a fast and reliable support system that you can turn to anytime.
We’ve created 4 teams of professionals to assist you, your staff and your clients throughout the quoting and on-boarding process. Click on the links below for more information.
Sales and Account Management - assists you with quoting and benefit design for groups with 51+ eligible employees
Team Service - provides support to you and your clients between renewals, addressing questions about enrollment, benefits and more
Team ReNEW - supports the administrative processes related to acquisition of new business and renewal of existing business
Individual Support Team - provides pre-sale support to you and individual buyers about our individual plan options.
Claims / Benefits
PO Box 9000
Johnston, IA 50131-9000
- Claim Form - Use to file out-of-network claims
- Authorization Form - Authorization to release personal health information
- Personal Representative Form
- Enrollment/Change Application - English version of employee enrollment form
- Enrollment/Change Application - Spanish version of employee enrollment form
- Voluntary PPO Application/Change Form (Employee English version)
- Voluntary PPO Application/Change Form (Employee Spanish version)
- DeltaVision Enrollment/Change Form (joint vision and dental employee application)
Employer Forms and Documents
- Application for Pooled Group (2-50 employees) and Voluntary PPO Coverage
- Application for Large Group Coverage (51+ employees)
- Quote Request Checklist (51+ employees)
- Notice of Financial Privacy Practices
- Guide for Administering Your Group Dental Benefit Plan
- ACH Form (fully-insured) - Form to have premium electronically withdrawn
- ACH Form (self-insured weekly) - Form to have weekly payment withdrawn