FORMS

AvMed makes it easy to manage your account by providing forms and other tools for making requests. Simply print and fill out one of our pre-composed forms for quick, easy service. Certain requests can be submitted directly online.

SMALL GROUP FORMS

 

• 2020 Small Group Master Application
• Affidavit of Extended Dependent Eligibility
• Appointment of Representative (Group members)
• COBRA form
• Common Ownership Form
• Continuation of Coverage (mini-cobra)
• Contractor Relationship - 1099 Affidavit
• Employee Enrollment Form
• Employer Risk Questionnaire
• Employee Status Change Form
• Member Disclosure Form
• Member Transition of Service Form – Medical and Pharmacy
• PEO Questionnaire Form
• Small Group Case Submissions Checklist
• Small Group Submission Deadline Calendar
• Small Group Underwriting Guidelines (Effective 1/1/2020)
• Waiver of Coverage

LARGE GROUP FORMS

• Affidavit Extended Dependent Eligibility
• Appointment of Representative (Group members)
• COBRA form
• Employee Status Change Form
• Employee Enrollment Form
• Employer Risk Questionnaire
• Large Group Submissions Checklist
• Large Group Commission Rate Agreement Form
• Large Group Underwriting Guidelines
• Member Disclosure Form
• Member Transition of Service Form – Medical and Pharmacy
• Waiver of Coverage