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Forms

Ease of Administration

We have compiled a list of the forms and items you may need when working with clients to offer the best Significa PPO plan options for their health care coverage needs.

Feel free to download these forms as you need them. If you have any questions or need a printed supply of the
Marketing Materials listed, please do not hesitate to contact us at 1-800-796-7460, weekdays from 8:30 a.m. until 4:30 p.m. E.S.T.

Getting Started
FIELD UNDERWRITING GUIDELINES
QUOTE REQUEST FORM
GROUP CENSUS TEMPLATE
NEW GROUP CHECKLIST
Applications
EMPLOYER APPLICATION (AZ)
EMPLOYEE APPLICATION (2-50)
Marketing Materials
PPO OPTIONS MATRIX
QHDHP PPO OPTIONS MATRIX
POS OPTIONS MATRIX
SIGNIFICARE BROCHURE
SIGNIFICARE MATRIX
SIGNIFICA AT A GLANCE BROCHURE
MYHEALTH
EXCLUSIONS
Other Forms
BENEFICIARY CHANGE FORM
CLAIM FORM
CHANGE/TERM FORM
DISABLED DEPENDENT APPLICATION
EXAMPLE OF AN EXPLANATION OF BENEFITS
LIFE ACCIDENTAL DEATH AND DISMEMBERMENT CLAIM FORM
Close

Please contact your Sales Executive, Jim Stults at (419) 366-9553 or via email at jim.stults@significa-ins.com.