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Forms Required to Enroll Groups of One or More

  • STEP 1: Download the CoOp Membership Agreement and save it on your desktop or in a folder. The form is an interactive PDF and can be filled out electronically. If you prefer, you may print, fill it out by hand, and scan before submitting the form in Step Two.
  • STEP 2: Submit the CoOp Membership Agreement to the CoOp by clicking the Submit button, and attaching it to the submission form. You may assist your business owner/employer in paying their CoOp Membership Fee by clicking the blue button at the bottom of this page.
  • STEP 3: Download the forms, complete, and sign. The forms are interactive PDFs and may be completed electronically, or if you prefer, printed, completed by hand, and signed. Submit the forms in Step 6. Note: the W-9 requires an original signature. 
  • STEP 4: Download the ACH Recurring Authorization form, which is an interactive PDF and may be filled out electronically. Attach a cancelled check before scanning and submitting in Step 6.
  • STEP 5: Download the Group Employer Eligibility Template. Provide this Excel format template to the HR department for populating from their census before submitting it in Step 6. An alternative is to require all enrolling employees to fill out the online enrollment application found on this website at sbafreedomplan.com/employee-enrolling-in-employer-plan.
  • STEP 6: Once you’ve completed and signed all remaining forms, you’re ready to upload them. Click the submit button, which will redirect you to the Regional Care, Inc. portal. Click the “Add Files” button, select all the files you want to upload, and click the Open button. Fill in your name, email address, and any comments you want to add in the pop-up window, and click Ok. Then click the Upload button to begin the quick uploading process. A small window will briefly appear at the upper right to notify you when your upload is complete.
Step 1

CoOp Membership Agreement
for the Group

Download CoOp Membership Agreement and save it
on your desktop. Complete form and submit.

Step 2

Submit CoOp Membership
Agreement Here

After completing the CoOp Membership Agreement,
click here to attach form and submit to the CoOp.
Assist your business owner/employer in paying their
CoOp Membership Fee by clicking the blue button
at the bottom of this page.

Step 3

W-9, Cost Calculator,
Group Information Form,

Download forms and save them to your desktop.
Complete forms and submit.

Step 4

ACH Recurring
Authorization Form

Download form and save it to your desktop.
Complete form and submit.

Step 5

Group Employer
Eligibility Template

Download form and save it to your desktop.
HR can complete the form for employee enrollment
OR they can direct their employees to complete
the Online Enrollment Form found on this website
under Employee Enrolling in Employer Plan.

Step 6

Submit All Remaining Forms
Here

After downloading and completing all remaining forms,
click here to upload them directly to the RCI portal.

Employers May Pay Their
CoOp Membership Fee Here

CoOp Membership will renew annually
on January 1, of each year.

*All Sales Are Final