New Small Group Processing Center

Below you will find the most common sales literature, applications, and forms used for Blue Cross of Idaho QHP Small Group products.

Applications & Forms

Form Description Form #
Census Input Sheet (.zip file)  
Employer Application and Group Questionnaire for New Small Group Coverage 3-549
Idaho Universal Group Application width Cover Sheet online-fillable form
  • For all groups excluding the below
3-1231
Idaho Universal Group Application with Cover Sheet and Health Statement online-fillable form
  • For all new medium groups
  • For all new large groups not using claims experience
  • For existing small grandfathered/ grandmothered groups if enrollment addition exceeds 20% threshold
3-1230
Employee Census Data 3-468
Employee's Waiver of Health Care Coverage 3-467
Third Party COBRA Notification 3-1125
Letter of Record 3-302
Group Authorization for Automatic Withdrawal 4-250

 

Sales Literature

Form Description Form #
2017 Small Group Product Plan Guide 3-1022
2017 Group Dental PLans 15-022