Requirements for Employers
New Groups Enrolling in Medical Plan(s)
*All IBC Forms Must be Originals.
- Completed Association Application for Small Employer Benefits form.
- A binder check equal to the first month's premium made payable to either Keystone Health Plan East if electing Keystone HMO or POS or Independence Blue Cross if electing Personal Choice or complete the signed Letter Of Authorization for Electronic Withdrawal as required and include a copy of a voided check. Please keep in mind this letter must be printed onto company letterhead, dated, and signed by an authorized officer, owner, or partner of the company. This will allow the first month's premium only to be deducted directly from your bank account.
- Copy of PA UC-2 report (this can be obtained from accountant or bookkeeper). If enrolling as a one person group, submit a copy of your architect's license and your most recent Schedule C in place of the UC-2 report.
- Completed employee enrollment forms.
- Completed Small Employer Health Benefits Waiver of Coverage for those employees waiving coverage.
- Gallagher Benefit Services, Inc. must receive all original forms no later than 20 days prior to the effective date of the coverage. Otherwise, the group will be delayed for another month before coverage becomes effective.
New Groups Enrolling in Dental Plan
- Completed United Concordia Group Enrollment Form
- Completed United Concordia Employee Enrollment Forms
Existing Groups Making Medical Plan Changes
- Completed Group Benefit Change Request Form
- Completed Employee Enrollment Forms if switching from Personal Choice to Keystone and vice versa.