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Applications & Forms

The following is a list of our online forms and applications. Looking for group sales literature?

Individual Medical

Group Medical

Private Exchange

Idaho Universal Group Application & Cover Sheet 3-1157C
Idaho Universal Group Application, Cover Sheet, & Addendum 3-1157C
 
Employer Application & Questionnaire - new small group coverage 3-549
Employer Application & Questionnaire - Mid Sized and Large groups 3-1208

Group Application

New! We've combined our coversheet and application into one PDF that can be used for all group sizes and both pre-ACA and post-ACA plans. We hope this makes the application process easier for you and your groups.

The Idaho Department of Insurance requires that a cover sheet be submitted with the Idaho Universal Group Application. In addition you may need to submit a health statement addendum. Links to the appropriate combined forms are listed below.

Large Group (51+ employees)
Idaho Universal Group Application, Cover Sheet, & Health Statement Addendum online-fillable form 3-1157C
Self-Funded (ASC), Trusts, Associations, etc.
Idaho Universal Group Application, Cover Sheet, & Health Statement Addendum online-fillable form 3-1157C
Small Group Grandfathered and Grandmothered
Idaho Universal Group Application, Cover Sheet, & Health Statement Addendum online-fillable form 3-1157C
QHP
Idaho Small Employer Application & Cover Sheet online-fillable form 3-1157C

Other Group Forms

Small GroupLarge GroupForm DescriptionForm #
X X Dual Option Application Cover Sheet 3-128
X   Employee Census Data 3-468
X X Employee's Waiver of Health Care Coverage 3-467
  X Employer Application & Group Questionnaire for New Groups 51 or more Employees 3-550
X   Employer Application & Questionnaire for New Small Group Coverage 3-549
X X Group Contact Change Form 3-1146
X   Group Quoting System Excel Roster (.zip file)  
  X Idaho Large Employer Group Application Cover Sheet - Spanish 3-186S
X X SBC Attestation 3-325
X X Third Party COBRA Notification 3-1125
X   Universal Idaho Small Employer Application - Spanish 3-017S

Dental Standalone

Group Standalone Dental Enrollment Application 3-395

Statewide Schools

Statewide Schools ASC Health/Dental/Vision Enrollment Application 3-307SWS

Voluntary Vision

Group Voluntary Vision Enrollment Application 3-412

Additional Forms/Resources

Resource Center

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