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Broker Forms

 

Small Groups (2-50 Eligible Employees)

 

Indiana-Based Employers
 

PDF DownloadIN Quote Request Grid (2-50 EE)

PDF DownloadUnderwriting Checklist (2-50 EE)

PDF DownloadUnderwriting Summary Sheet

PDF DownloadMedical Questionnaire with Waiver (2-25 EE)

PDF DownloadMedical Questionnaire (26-50 EE)

PDF DownloadWaiver Form (26-50 EE)
 

Kentucky-Based Employers
 

PDF DownloadKY Quote Request Grid (2-50 EE)

PDF DownloadUnderwriting Checklist (2-50 EE)

PDF DownloadUnderwriting Summary Sheet

PDF DownloadMedical Questionnaire with Waiver (2-50 EE)
   

Large Groups (51+ Eligible Employees)

 

Indiana-Based Employers
 

PDF DownloadUnderwriting Checklist (51+ EE)

PDF DownloadUnderwriting Summary Sheet

PDF DownloadWaiver Form (51+ EE)

PDF DownloadMedical Questionnaire (51+ EE) - only when requested by WHP
 

Kentucky-Based Employers
 

PDF DownloadUnderwriting Checklist (51+ EE)

PDF DownloadUnderwriting Summary Sheet

SOLD Employer Group Forms

 

PDF DownloadIndiana Enrollment Application

PDF DownloadKentucky Enrollment Application

 

Medicare Brokers:

PDF DownloadMedicare AppFax Program

 

Welborn Health Plans
Welborn Health Plans

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