Employer Checklist

EMPLOYER CHECK LIST FOR HEALTH INSURANCE APPLICATIONS

As the employer there are certain items that you are responsible for before a health insurance application may be processed for you or your employees.

Please note the following:

• Please read over the Enrollment Guidelines from the Carrier that are included in the health insurance comparison package supplied by the Chamber*. There are separate guidelines for companies that have employees and sole proprietors. Please follow the guideline that pertains to your company type.

• Fill out and sign the employer section on the health insurance application. This appears in a different location on each carrier's application. Make sure that all of the information is clearly marked.

• Make sure that the date of hire is clearly marked on the application. New hires must apply for health insurance within two weeks of their hire date.

• Please sign the application in the area marked Group Administrator. You are your employees' administrator. The Chamber has no relationship or control over your employees.

• Please complete and sign the Group Membership Information form supplied by each of the carriers. This information pertains to your company and must be completed fully in order for the application to be processed.

• Please provide any supporting documentation that is required by the carrier. These documents are listed on the Group Membership Information form. These include, but are not limited to, a DBA certificate, NYS-45 tax form or other tax forms.

• Please complete the employer section on the Policy Selection Form. If available, please include an e-mail address for yourself or the subscriber. We are compiling a database of e-mails to provide quick notification of changes or notices regarding the health insurance plans for those subscribing to plans through the Chamber.

• For NEW APPLICATIONS please include a $25.00 non-refundable application processing fee for each application being submitted. This check should be made payable to the Hamburg Chamber of Commerce.

• For RECERTIFICATION APPLICATIONS please include a $10.00 non-refundable rectification fee for each application being submitted. This check should be made payable to the Hamburg Chamber of Commerce.

MEMBER SERVICES INFORMATION:

Independent Health Association: 1-800-501-3439

*This document is for comparison only. Please see actual plan book for complete and specific information. If there are any inadvertent discrepancies between this summary and the actual contract, the contract will prevail.