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.

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

In the Pennsylvania counties of Lancaster and York please contact your Sales Executive, Kim Good at (717) 581-1300 Ext. 216 or via email at kgood@significabenefits.com.

In all other Pennsylvania counties please contact your Sales Executive, Anne Perkins at (717) 201-6627 or via email at aperkins@significa-ins.com.