Group Size 51+ Eligibles

Enrollment Material Checklist

THE FOLLOWING ITEMS ARE REQUIRED FOR A COMPLETE GROUP APPLICATION

_____1.	Employer Group Application (GOA) Worksheet
_____2.	Enrollment Application/Change Form and Waiver of Residence Requirement An Enrollment Application must be completed for each employee who is enrolling in Care Choices. Include the name of the Primary Care Physician selected by each employee (and applicable dependent) The employee and employer must sign and date this form.
_____3.	Name of Worker's Compensation Insurance Carrier Must include policy number, renewal date.
_____4.	Quarterly Wage Detail Report (51-99 Eligibles) Include a copy of the group's most recent quarterly wage and tax report.
_____5.	Agent of Record (AOR) Confirmation (Applicable for agent enrolled groups) May be verified with the employer's signature on the Employer Group Application or with an AOR letter from the employer.
_____6.	First month premium payment. The employer premium check should be made payable to Care Choices HMO. Your application will not be considered complete without the premium payment.

Please return the above documents along with the first monthly premium to:

Care Choices HMO
Sales Department
34605 12 Mile Rd.
Farmington Hills, MI 48331

Contact Care Choices Business Support with questions at (800) 261-3452.