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Broker Information

Broker Forms

 

Small Groups (2-50 Eligible Employees)

	Indiana / Kentucky - Based Employers
	Indiana Quote Request Grid (2-50 EE) KY Quote Request Grid (2-50 EE) Underwriting Checklist (2-50 EE) Underwriting Summary Sheet Medical Questionnaire with Waiver (2-25 EE) Medical Questionnaire (26-50 EE) Waiver Form (26-50 EE)

Large Groups (51+ Eligible Employees)

	Indiana / Kentucky -Based Employers
	Underwriting Checklist (51+ EE) Underwriting Summary Sheet Waiver Form (51+ EE) Medical Questionnaire (51+ EE) - only when requested by WHP

SOLD Employer Group Forms

Indiana Enrollment Application Kentucky Enrollment Application

 

Medicare Brokers:

Medicare AppFax Program