Forms for Employers

These forms are in portable document format (PDF). You may print and copy as needed.

• Application for Conversion Policy (64 KB PDF)
• Blueprint for Employers Registration Form (50 KB PDF)
• Blueprint for Employers Web Administrator Change Form (34 KB PDF)
• Change Request Form (49 KB PDF) (Not for use by BluesEnroll Groups)
• Dental Application and Change Form (68 KB PDF)
• Dental Claim Form (622 KB PDF)
• Group Administrator's Manual (598 KB PDF)
• Health Claim Form (81 KB PDF)
• Large Group Employee Application (106 KB PDF)
• Medical Questionnaire for Late Enrollees (156 KB PDF)
• MyChoice Blue Employee Selection Form (2072 KB PDF)
• MyChoice Blue Initial Enrollment Option Change Request Form (2074 KB PDF)
• Prescription Claim Form (882 KB PDF)
• Small Group Employee Application (125 KB PDF)
• Student Verification Form (82 KB PDF)
• State of Arkansas Continuation of Coverage Election Form (39 KB PDF)