Forms & guides

Administer your company’s health benefits with these forms and benefit administration guides. To order employee or group purchaser materials, download a material order form below and fax it to (651) 662-1657.

Small groups (2-50 employees)

Average Employee Count Calculation (PDF)

“Welcome to Blue Cross” brochure for employees (PDF)

“Welcome to Blue Cross” brochure for employees - Spanish (PDF)

Easy administration guide – Small groups (PDF)

Benefit administrator guide – Small groups (PDF)

Change form – Small groups (PDF)

Employee application – Small groups (PDF)

Employee application in Spanish – Small groups (PDF)

Employee or dependent cancel form – Small groups (PDF)

Materials order form – Small groups (PDF)

HIPAA notice of pre-ex and special enrollment – Small groups (PDF)

Non-reform application – Small groups (PDF)

Reform application – Small groups (PDF)

GenRx employee communication – Small groups (MS Word)

Large groups (over 50 employees)

Benefit administrator guide – Large groups, fully insured (PDF)

Benefit administrator guide – Large groups, self insured (PDF)

Enrollment and change form – Large groups (PDF)

Materials order form – Large groups (PDF)

Notice of pre-ex and notice of special enrollment – Large groups (PDF)

Minnesota Service Cooperatives

Notice of pre-ex and notice of special enrollment – Service Cooperatives (PDF)

Benefit administrator guide – Service Cooperatives (PDF)

Plan election form – Service Cooperatives (PDF)

COBRA

COBRA & Continuation Election Notice (PDF)

COBRA General Notice (PDF)

COBRA and Minnesota Continuation Laws booklet (PDF)

Medicare

Medicare Part D – Creditable coverage plans chart (PDF)

Medicare Part D – Non-personalized (generic) non-creditable coverage letter (template)

Medicare Part D – Non-personalized (generic) creditable coverage letter (template)

Medicare secondary payer reporting – sample mailing with SSNs (PDF)

Medicare secondary payer reporting – sample mailing without SSNs (PDF)

Other forms

Plan Election Form – Fully insured groups (PDF)

Premium Contribution Reporting Tool (MS Excel) – only for fully insured groups, to determine grandfathered status

Plan Election Form – Self-insured groups (PDF)

Retiree Only Group Attestation Form (PDF)

Automatic fund transfer instructions (PDF)

Student dependent information request (PDF)

CHIP sample notification for employees (PDF)

Grandfathered plans model notice (MS Word)

Massachusetts Health Care Reform Filing Service (MS Word)


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