Small Group Program

Enrollment Material Checklist

THE FOLLOWING ITEMS ARE REQUIRED FOR A COMPLETE SMALL 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.

Employer Group Roster

This roster is used to verify the employment status of all employees who are enrolling in Care Choices. The roster must be signed and dated by the employer.

_____4.

Employee Waiver Form

Form required for any employee waiving coverage.

_____5.

Copy of Worker's Compensation insurance certificate

Must include policy number, renewal date and name of carrier.

_____6.

Quarterly Wage Detail Report

Include a copy of the group's most recent quarterly wage and tax report. Indicate FT, PT, terminated and new hires on the report. For owners who do not appear on the Wage report and for existing Grandfathered Sole Proprietorships: Schedule 1065, 1120, K1 or C with 1040 documents may be used in place of quarterly Wage Detail Report.

_____7.

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.

_____8.

Copy of rates with input sheet if agent generated.

_____9.

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 all required items listed above to: Care Choices HMO Sales Department - Small Group Program 34605 12 Mile Rd. Farmington Hills, MI 48331

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

Group Size 2-50 Eligibles

Enrollment Material Checklist