Group Benefits

Forms > Humana

 

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

Humana Enrollment Kit as one file
Medical Only 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 Business Information Application (3/08)
Employer Medical Selection Application 2-99 (12/08)
Employee Application 2-50 (3/08)
 
Additional Lines of Coverage:

Employer Application for Disability (STD/LTD)

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

Personal Care Account (PCA) Forms
Employer Group Application PCA
 
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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