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. Anthem Blue Cross HMO Enrollment Form for Employees
2. Delta Dental and/or Vision Service Enrollment Form for Employees
3. Group Life/Group Disability Enrollment Form
4. Life-LTD Health Statement
   (For firms enrolling 3 or fewer persons in the Group Life or Group LTD program.)
5. ProtectPlus Enrollment form for your employees (For firms of 2 or more)
6. ProtectPlus Enrollment form for Solo Practitioners (Use also for late enrollees)
7. Subscription Agreement
   (Your firm need only complete one subscription agreement regardless of how many group plans you elect.)
8. Census Form (Use for obtaining a quote from Banyan Administrators, LLC).
9. Open Enrollment Change Report (Use to make changes to your firm's group health plans during open enrollment.)