Employers

Forms and group administrator manual

The forms listed on the menu below are for use by employers. These forms are in portable document format (PDF). You may print and copy as needed.

Blueprint for Employers registration form [pdf]
Blueprint for Employers chief administrator change form [pdf]
Change request form [pdf]
This form is used to make changes to a currently enrolled employee's address, name and telephone number or to cancel coverage for an employee and/or dependent(s).
Dental claim form [pdf]
Employee application [pdf]
Employee application — Spanish version [pdf]
Enrollment application with medical questionnaire [pdf]
Enrollment application with medical questionnaire — Spanish version [pdf]
Explanation of payment form [pdf]
Health claim form [pdf]
Use this form to submit medical charges for benefits that were not filed by the physician or healthcare professional. There are step-by-step instructions on how to file charges on the reverse side of the claim form.
Newborn enrollment request [pdf]
Prescription claim form [pdf]
Proof of incapacity of a dependent - Physician's form [pdf]
Proof of incapacity of a dependent - Policyholder's form [pdf]
Reinstatement Form [pdf]
State of AR continuation of coverage election [pdf]
Vision claim form [pdf]
If you choose to see an out-of-network provider, submit your itemized receipt(s) along with the out-of-network reimbursement form. You will be reimbursed the allotted amount based on your benefits.