Health Insurance Forms Your Clients Need to Complete or Submit


Many forms are required as part of the quoting, underwriting, and enrollment process for Group Health Insurance. Some can be completed electronically. Others have to “signed” and returned to get the application and enrollment process started. Here’s an overview of what you and your clients can expect.

It All Starts with a Quote

To get a quote for a new or existing client, we’ll need a current group census showing the desired effective date, employer information (name, ZIP Code, type of business, and current carrier, if applicable), as well as the names, birth dates, salary, and job titles of the proposed insured employees (and dependents, if applicable). Sometimes, not all of this information is required, although the form does include these fields; ask your Word & Brown representative or the Underwriting team about what is essential. If your client is an Applicable Large Employer (ALE), the business is subject to the Affordable Care Act (ACA) employer mandate. Link here for more information on the Internal Revenue Service website.

Click on the links below to download our census forms:

  • California Census Form ADD LINK TO EXCEL FORM
  • Nevada Census Form ADD LINK TO EXCEL FORM

For Large Group business, be sure to include the Request for Proposal Template with your RFP request. You can use the same census form for Large Groups and Small Groups.

Carrier Forms

Forms needed for your client’s selected health plan(s) will vary by state and carrier; however, at a minimum, the employer will need to complete an Employer Application. (If applicable, be sure you complete the Agent Attestation section.) Each enrolling employee will need to complete an Employee Application, and those who waive coverage will likely need to complete a waiver form. We recommend collecting employee waivers, even if the carriers do not require the employer to do so. Having waivers on file can aid an employer tremendously down the line. (Click here to read a related article by Compliance Manager Paul Roberts.)

After you log in, you can access California enrollment forms here, and Nevada forms here. Carrier-specific enrollment kits include the case submission checklist, enrollment forms, and related materials needed to enroll your groups. You can download each of the documents in the enrollment kits, or you can email them directly to your clients for completion and return to you. (The carrier checklist is a reminder for you; it’s not for the employer.) All other carrier forms can be found in the general California forms section or Nevada forms section. Be sure to select your market segment and health carrier to find the forms you need.

Some carriers require a Quarterly/Annual Wage Report (DE 9C in California, NUCS 4072 in Nevada). Be sure you indicate the current employment status for each employee listed (e.g., full-time, part-time, or terminated). Payroll information may be required for new hires not listed on the quarterly report. An eligibility statement is needed for officers or owners not listed on the quarterly summary.

Be sure to review the carrier’s Submission Checklist, if applicable, or underwriting guidelines for a complete list of requirements. Additional items and documentation are required for some groups by some insurers.

If the group is a take-over (moving from one carrier/health plan to another), the prior/last month’s group premium statement is required. A copy of your group’s quote is needed with your submission. Incomplete forms will be returned, which could lead to a processing delay.

An Electronic Debit Payment form (along with a voided check) or company check is usually required for the first month’s premium.

If you are not already appointed with the carrier selected by your client, additional forms may be required for you – such as a broker licensing form or direct deposit form for payment of your commissions. Both are available online for most carriers.

Other Useful Forms

To help your clients comply with ACA requirements, we encourage you to provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at your scheduled enrollment meeting(s) – or via email or online using the employer’s internal company website.

Click the links below to access the SBCs for your state:

California Network Comparisons

If you’re writing coverage in California, you have access to five regional network comparisons showing what Medical Groups and IPAs are contracted for each carrier’s plans.

Health Plan Reference Guides

Word & Brown’s exclusive HPRGs – available in four editions – offer vital market- and state-specific product, carrier, underwriting, renewal, eligibility, and other information in one convenient place.

  • California Small Group HPRG ADD LATEST LINK
  • California Large Group HPRG ADD LATEST LINK
  • Nevada Small Group HPRG ADD LATEST LINK
  • Nevada Large Group HPRG ADD LATEST LINK


If you have questions about any of the forms used in getting a quote or enrolling your new groups, contact your Word & Brown representative. If you have questions about forms existing group changes, contact Account Management via email at or call 866-380-0053.


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