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
GETTING APPOINTED
	QUOTE REQUEST FORM
	GROUP CENSUS TEMPLATE
	NEW GROUP CHECKLIST
	FIELD UNDERWRITING GUIDELINES
	ADDITIONAL ADMINISTRATIVE SERVICES
Applications
	EMPLOYER APPLICATION
	ENROLLMENT APPLICATION
Marketing Materials
	SIGNIFICA'S SEAMLESS SERVICE
	PPO OPTIONS MATRIX
	QHDHP PPO OPTIONS MATRIX
	SIGNIFICARE BROCHURE
	SIGNIFICARE MATRIX
	SIGNIFICA AT A GLANCE BROCHURE
	EXCLUSIONS
Other Forms
	BENEFICIARY CHANGE FORM
	CLAIM FORM
	CHANGE/TERM FORM
	DISABLED DEPENDENT APPLICATION
	LIFE ACCIDENTAL DEATH AND DISMEMBERMENT CLAIM FORM

Please contact your Sales Executive, Jim Nicholakis at (614) 499-5217 or via email at jim.nicholakis@significa-ins.com.