Resources for Plan Administrators & Employers
Please Select from the Carriers Below for Forms & Applications
- Claim Form - Rx
- COBRA Form
- Domestic Partnership Declaration
- Gym Reimbursement Form
- Incapable Dependent Child Certification Form
- Late Paperwork Form
- Letter of Certification - Sole Proprietor
- Submission Checklist
- Waiver of Coverage Form
- Young Adult Election-Eligibility Form
- Claim Form
- Small Group Late Submission Acknowledgement Form
- Waiver Form
- 2022 Individual Underwriting Guidelines
- CAI EFT Form
- Benefit Description - Employee Assistance Program
- Benefit Description - Rx Program FAQs (an excerpt from EmblemHealth FAQs)
- Benefit Description - Women's Preventive Services - Effective 8-1-12
- EmblemHealth ACP Information
- EmblemHealth Teladoc Information
- 2022 Network Brochure
- 2023 Individual Basic/Catastrophic Plan Summary
- 2023 Individual Bronze D Plan Summary
- 2023 Individual Gold D Plan Summary
- 2023 Individual Platinum D Plan Summary
- 2023 Individual Silver D Plan Summary
- 2023 Small Group Bronze Plus HSA
- 2023 Small Group Bronze Premier
- 2023 Small Group Gold Premier
- 2023 Small Group Platinum Premier
- 2023 Small Group Silver Plus HSA
- 2023 Small Group Silver Premier
- 2023 Q1 Small Group Rates-Long Island (Region 8)
- 2023 Q1 Small Group Rates-Metro (Region 4)
- 2023 Q1 Small Group Rates-Mid-Hudson (Region 3)
- 2023 Q2 Small Group Rates-Long Island (Region 8)
- 2023 Q2 Small Group Rates-Metro (Region 4)
- 2023 Q2 Small Group Rates-Mid-Hudson (Region 3)
- 2023 Q3 Small Group Rates-Long Island (Region 8)
- 2023 Q3 Small Group Rates-Metro (Region 4)
- 2023 Q3 Small Group Rates-Mid-Hudson (Region 3)
- 2023 Q4 Small Group Rates-Long Island (Region 8)
- 2023 Q4 Small Group Rates-Metro (Region 4)
- 2023 Q4 Small Group Rates-Mid-Hudson (Region 3)
Dental Insurance
- Benefit Description - ENHANCED
- Benefit Description - HIGH
- Benefit Description - MEDIUM
- Benefit Description - PREMIER
- Benefit Description - Preventive Incentive Rider - HIGH
- Benefit Description - Preventive Incentive Rider - MEDIUM
- Benefit Description - Vision Plan - Davis Vision (Included with Dental Plan)
- Fast Facts
- Online Services for Plan Subscribers
- Provider Listing - Downstate NY (Use of On-Line Provider Link Recommended)
- Provider Listing - Find a Dentist On-line (Instructions)
- Provider Listing - Upstate NY Region (Use of On-Line Provider Link Recommended)
- Benefit Description - Unlimited
- Teledentistry Guide
- Rates - Dental - 2022
- Rates - Dental - 2023
Vision Insurance
Life Insurance
Hospital Indemnity Plans
Disability Insurance
- APPLICATION FORMATTING - PAGE ORDER - ALL POLICIES
- Application Instructions - Business Overhead Expense
- Application Instructions and Checklist - All Policies
- Enrollment Application - Agreement - UN 2550 AG 2-12 NY
- Enrollment Application - Authorization - UN 2550 AU 2-12 NY
- Enrollment Application - Conditional Receipt - UN 2550 CR 2-12 NY
- Enrollment Application - Health Questionnaire - UN 2550 HQ 2-12 NY
- Enrollment Application - Lifestyle Questionnaire - UN 2550 LQ 2-12 NY
- Enrollment Application - Notice of Insurance Information Practices - UN 2550 NI 2-12 NY
- Enrollment Application - Occupation and Financial Information - UN 2550 DI FI 10-11 NY
- Enrollment Application - Personal Information - UN 2550 PI 10-11 NY
- Enrollment Application - Policy Details - UN 2550 DI 10-11 NY
- Enrollment Application - Producers Statement - UN 2550 PS 10-11 NY
- Enrollment Application - Why Second Authorization - UN 1447 NY
