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Brokers > Forms

Access Printable Forms

Please choose from the list below to download an adobe acrobat pdf file. If you do not have acrobat reader you can download it here or click the acrobat reader logo below the list to download the free program.

Selling Agent Forms

Broker Enrollment Contract
Policy Broker of Record Letter (BOR)
Broker and GA Direct Deposit Authorization

Submitting for a Group

Case Installation Sales Regulation
Group Agreement Form
Notice of Enrollment Period and Waiver Period Form
Previous Insurance Coverage Form
Health Insurance Claim Form (HCFA 1500)
Employer Member Enrollment & Physician Selection Application
Atlantis Rewards Program Application
Healthy New York Individual Application
Healthy New York Group Application
Credit Card Authorization Form