Group Documentation

The Blue Cross of Idaho forms for group sales and ongoing client support are located in the lists below.

Mid-Size and Large Group Quoting Documents

Use these forms to request quotes for Mid-Size and Large Groups. Send completed forms to your Blue Cross of Idaho Sales Consultant. Select Small Group quoting to access EZ Quote.

Sold Group Implementation Documents

We encourage online enrollment whenever possible as it speeds up the application processing time, which provides your client access to their benefits on their coverage effective date. If it is necessary to submit paper enrollment applications, please remember to submit accurate, legible and complete information. Send group enrollment information to SalesOpsImplementation@bcidaho.com

Small Group

online-fillable form Online-fillable form

New Small Group Onboarding Requirements

Document Form Number
Small Group Checklist 3-1272
Completed and Signed Quote EZ Quote
Group CensusTemplate
   - See Creating a Group Census for Requirements
Excel Worksheet
Small Group Questionnaire online-fillable form 3-549
SUTA (or applicable tax documentation) Employer
E-check/ACH Payment Authorization Form 4-255NI
Idaho Universal Application and Coversheet online-fillable form 3-1231

 

Mid-Size Fully Insured

online-fillable form Online-fillable form

Blue Cross of Idaho Doucumentation

Document Form Number
Idaho Universal Application and Coversheet online-fillable form
  - OR -
Electronic enrollment file (834 file format/One time Proprietary format)
3-1231
Idaho Universal Group Health Statement Addendum online-fillable form  
Large Group Employer Application/Questionnaire (includes Letter of Record) online-fillable form
  - OR -
Mid-Size and Large Employer Application/Questionnaire for Private Exchange
3-550

3-1208
Census (BCI form not required, Excel preferred) online-fillable form 3-468
ACH/E-Check Withdrawal For Monthly Premiums (optional) 4-255NI
Third Party COBRA notification online-fillable form 3-1125

Other Documentation

Document Source
Copy of signed/dated sold option(s) Quoting tool

Mid-Size Balanced Funding

online-fillable form Online-fillable form

Blue Cross of Idaho Doucumentation

Document Form Number
Idaho Universal Application and Coversheet online-fillable form
  - OR -
Electronic enrollment file (834 file format/One time Proprietary format)
3-1231
Idaho Universal Group Health Statement Addendum online-fillable form  
Employer Group Application and Questionnaire ASC (includes Letter of Record) 3-437
Census (BCI form not required, Excel preferred) online-fillable form 3-468
Third Party COBRA notification online-fillable form 3-1125
ACH/E-Check Withdrawal For Monthly Premiums (optional) 4-255NI
HIPAA Documents

Other Documentation

Document Source
Copy of signed/dated sold option(s) Quoting tool

Large Fully Insured

online-fillable form Online-fillable form

Blue Cross of Idaho Doucumentation

Document Form Number
Idaho Universal Application and Coversheet online-fillable form
  - OR -
Electronic enrollment file (834 file format/One time Proprietary format)
3-1231
Large Group Employer Application/Questionnaire (includes Letter of Record) online-fillable form
  - OR -
Mid-Size and Large Employer Application/Questionnaire for Private Exchange
3-550

3-1208
Census (BCI form not required, Excel preferred) online-fillable form 3-468
ACH/E-Check Withdrawal For Monthly Premiums (optional) 4-255NI
Third Party COBRA notification online-fillable form 3-1125
HIPAA Documents

Other Documentation

Document Source
Copy of signed/dated sold option(s) Quoting tool

Large Balanced Funding

online-fillable form Online-fillable form

Blue Cross of Idaho Doucumentation

Document Form Number
Idaho Universal Application and Coversheet online-fillable form
  - OR -
Electronic enrollment file (834 file format/One time Proprietary format)
3-1231
Employer Group Application and Questionnaire ASC (includes Letter of Record) 3-437
Census (BCI form not required, Excel preferred) online-fillable form 3-468
Third Party COBRA notification online-fillable form 3-1125
ACH/E-Check Withdrawal For Monthly Premiums (optional) 4-255NI
HIPAA Documents

Other Documentation

Document Source
Copy of signed/dated sold option(s) Quoting tool
1st Month Premium Employer

Large Self-Funded (ASC)

online-fillable form Online-fillable form

Blue Cross of Idaho Doucumentation

Document Form Number
Idaho Universal Application and Coversheet online-fillable form
  - OR -
Electronic enrollment file (834 file format/One time Proprietary format)
3-1231
Employer Group Application and Questionnaire ASC (includes Letter of Record) 3-437
Census (BCI form not required, Excel preferred) online-fillable form 3-468
Third Party COBRA notification online-fillable form 3-1125
ACH/E-Check Withdrawal For Monthly Premiums (optional) 4-255NI
ACH Withdrawal for weekly claims payments (optional) online-fillable form 3-1170NI
HIPAA Documents

Other Documentation

Document Source
Copy of signed/dated sold option(s) Quoting tool

Idaho Schools Benefit Trust

online-fillable form Online-fillable form

Blue Cross of Idaho Doucumentation

Document Form Number
ASC Health/Dental/Vision Enrollment Application online-fillable form
  - OR -
Electronic enrollment file (834 file format/One time Proprietary format)
3-307SWS
Employer Group Application and Questionnaire ASC (includes Letter of Record) online-fillable form 3-437
Census (BCI form not required, Excel preferred) online-fillable form 3-468
Third Party COBRA notification online-fillable form 3-1125
ACH/E-Check Withdrawal For Monthly Premiums (optional) 4-255NI
Commission Agreement  
SWS Retiree Application online-fillable form 4-150

Other Documentation

Document Source
Copy of signed/dated sold option(s) Quoting tool
Idaho School Benefit Trust Employer Participation Agreement  

Idaho AGC Health Plan

online-fillable form Online-fillable form

Blue Cross of Idaho Doucumentation

Document Form Number
Idaho AGC Application