Brokers Entity Forms Download

Brochures & forms for groups from 2 - 50 employees. California only product. Includes benefits for chiropractic and acupuncture services. The documents provided below are in PDF file format. To view and/or print these documents you will need Acrobat Reader installed.

BROCHURES

Rate and Benefit Flyer
Chiropractic Study - Members with vs. Members without
Chiropractic Evidence of Coverage Booklet
Acupuncture Evidence of Coverage Booklet
Chiropractic & Acupuncture Evidence of Coverage Booklet
"Easy as 1-2-3" Flyer (M190-002C)

FORMS

Group Election Form
Member Enrollment Form
One-Time Census Layout Template
ASH Plans Producer Agreement - Graded
ASH Plans Producer Agreement - 0%
W-9 Form
Monthly Membership Change Form
HICN or SSN Alert
Reason for Refusal of HICN or SSN Form