• Dental Census
• Disability Census
• Life Census (Flat Amount)
• Life Census (Multiple of Salary)
• Medical Census
• Medical & Dental Census
• Medical, Dental, Life & Disability Census
• State of NH Standardized Health Form
• Underwriting Questionnaire

• Authorization to Release Information
(Benefit Administrator)
• Authorization to Release Information
(Individual)
• Dependent Student Certification
• Enrollment Agreement
• Enrollment/Member Change (HMO)
• Enrollment/Member Change (HSA)
• Enrollment/Member Change (PPO)
• Mail Service Pharmacy Enrollment
• Medicare Supplemental
• Notice of Membership Change
• Prescription Drug Claim
• Subscriber Claim


• Mail Order Rx
• Membership Application & Change
• Member Claim
•Notice of Membership Adjustment
• Prescription Drug Claim

• Claim Form (POS)
• Claim Form (PPO)
• Enrollment Form (HMO)
• Enrollment Form (POS)
• Enrollment Form (PPO)
• Health Care Coverage Waiver (MA)
• Health Care Coverage Waiver (MH, ME)
• PacifiCare Behavioral Health Claim
• Prescription Claim

• Enrollment/Change
• Claim Form
• Termination Report

• Individual Authorization
• Enrollment
• Claim Form
• Domestic Partner Authorization


• Administrator of Record
• Enrollment/Change
• Group Set Up Agreement
• Mail Order Rx
• Medical Reimbursement
• New Business Checklist
• Student Waiver
• Waiver of Coverage