Forms for Downloading2020-09-13T00:17:20+00:00

Forms for Downloading

Employer Group Enrollment Forms

CoOp Membership Agreement2018-09-28T21:07:21+00:00
Employer Freedom Plan Checklist2021-07-27T21:13:42+00:00
Group Information Form2018-09-28T20:37:45+00:00
W-9 (for the group)2018-09-28T20:39:51+00:00
SB/A CoOp Employer Application2020-12-22T21:21:57+00:00
ACH Authorization Form for Employer Groups2020-12-22T18:57:31+00:00
Group Census Eligibility Template in Excel Format2018-09-28T21:01:30+00:00
RCI Coverage Change Form2021-01-18T20:53:19+00:00

Employee Forms

Employee Enrollment Application (paper form)
Note: After completion of the Employee Enrollment Application, please submit to Employer Human Resources.
2021-07-26T19:28:06+00:00

Broker Contracting Forms

CoOp Membership Agreement2018-09-28T21:07:21+00:00
Broker Appointment Form2018-09-28T20:57:46+00:00
Broker W-92018-09-28T21:04:04+00:00
CoOp Broker Agreement (Compensation)2020-09-13T00:48:31+00:00
Employer Freedom Plan Checklist2021-07-27T21:13:42+00:00