Group Benefits

Forms > Humana
 
 
Please submit Humana licensing prior to submitting a Humana case.  Please contact Shea Gamble sgamble@resourcebrokerage.com with any questions.



You must be active in Humana’s system in order to submit a case with us.  If you are not an active Humana Agent please submit licensing ASAP to sgamble@resourcebrokerage.com.  Humana will not process any cases from an agent who is not active in their system.  The employer paperwork and employee applications MUST BE DATED ON or AFTER the date in which the agent is active; otherwise, Humana will request new dates to be submitted.
 

Underwriting Days
Humana Enrollment Kit as one file
Humana Enrollment Kit 2011
51-99 Enrollment Kit
Enrollment Kit as Separate Forms (Medical, Dental & Life)
 
Required Documents to Enroll for Medical:
Humana Checklist
ACH Form - Required for all new business cases
Employer Group Application (EGA) 3/08
Employer Medical Selection Application 2-99 (12/08)
Illinois Standard Health Employee Application for Small Employers
 
Additional Lines of Coverage:

Employer Application for Disability (STD/LTD)

Employee Application for Disability (STD/LTD)
 
Employer Dental Application (2/10)
Employer Vision Application (12/08)
Employer Life Application (3/08)
Employee Application for Ancillaries Only (6/08)
 

Personal Care Account (PCA) Forms
Employer Group Application PCA 3/2011
 
Miscellaneous Forms
Humana Dependent Information
Additional Details to Medical Questions
Multi-location Form
Eligibility Certification Form
Consent for Release of PHI
51+ Risk Assessment Form
Full-time Employment Questionnaire
Plan Change Form (6/08)
 
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