Enrollment Forms

You will need Adobe Acrobat Reader 4.0 or higher to view the forms listed below. You can obtain Acrobat Reader for free by clicking here. Please note that solo practitioners (one CPA, no employees) are subject to underwriting and must complete the health statement included in the ProtectPlus Enrollment form for Solo Practitioners. Solo Practitioners may be denied coverage based on their personal health history. If denied coverage, Solo Practitioners may be eligible for coverage under a ProtectPlus HIPAA plan and if applicable, will be advised of their HIPAA eligibilty by the plan administrator.

Enrollment Documents

1. Subscription Agreement (Employer Application for all size firms)
   (Your firm need only complete one subscription agreement regardless of how many group plans you elect.)
2. Medicare Secondary Payer (MSP) Statement (Applicable to firms with fewer than 20 employees)
3. Medical/Dental/Vision Enrollment form for Employees (For firms of 2 or more. All employees must complete the form. Employees waiving coverage must complete the waiver section.)
4. Medical/Dental/Vision Enrollment form for Solo Practitioners (Use also for late enrollees)
5. Delta Dental and/or Vision Service Enrollment Form for Employees (If enrolling in Dental and/or Vision only)
6. Group Life-LTD Health Statement
   (For firms enrolling 3 or fewer persons in the Group Life or Group LTD program.)
7. Group Life-LTD Employee Enrollment Form (for groups of 2-9 only)

Related Forms

1. Rate Renewal Calendar
2. Census Form (Use for obtaining a quote from Banyan Administrators, LLC).
3. Open Enrollment Change Report (Use to make changes to your firm's group health plans during open enrollment.)