Broker Forms

REGISTRATION FORMS

• Agent Commission Agreement
• Broker Registration Form
• Commercial Underwriting Guidelines
• Notice of Privacy Practices
• W-9

ONLINE ACCESS / DIRECT DEPOSIT

• Broker Commission On Line Registration Form

INDIVIDUAL ENROLLMENT FORMS

• ACCESS HEALTHPLEX INDIVIDUAL APPLICATION
• Enrollment Form For GCDIY3
• Select NY Individual Enrollment Form

GROUP PLAN ENROLLMENT FORMS

• Dentcare Group Application - New York
• Dentcare Group Application Spanish - NY
• HIC Group Application
• Healthplex Preferred Choice (H7) Group Application - New York
• IHS CapDent/CapDent Plus Group Application - New Jersey

CLAIM FORMS

• ADA Claim Form

GROUP PAYMENT

• Dentcare Group Payment Form
• Dentcare Group Payment Form Spanish
• Healthplex Group Payment Form
• IHS Group Payment Form

OTHER

• CAA COMPENSATION DISCLOSURE RESOURCE GUIDE
• Change Of Broker Letter
• Dependent Student Certification Form
• Flyer For Managed Care And Select
• Flyer For Managed Care And Select
• Group Transmittal Form (Add/Term Members)
• Managed Care Brochure
• National PPO Brochure
• National PPO Brochure
• Subscriber Change Form

GROUP CONTRACT

• Group Contract HIC

EXCHANGE FORMS

• Group/Shop Adult/Family Enrollment Form Dentcare
• Group/Shop Adult/Family Enrollment Form HIC
• Group/Shop Pediatric Enrollment Form Dentcare
• Group/Shop Pediatric Enrollment Form HIC
• Group/Shop Pediatric Enrollment Form HIC
• Individual Adult/Family Enrollment Form Dentcare
• Individual Adult/Family Enrollment Form HIC
• Individual Pediatric Enrollment Form Dentcare
• Individual Pediatric Enrollment Form HIC