Secure Plans Forms

Checklists

Enrollment Checklist

Time to sign up? Here is what you’ll need.

Enrollment Forms

Please note: Self-funded plans require more forms than self-funded plans. They are regulated by more agencies and some of forms are personalized to the group. The Administrator will prepare these additional forms after receiving forms listed below.

Employee

Employee Application

Ask about online applications
from EasyAppsOnline and FormFire

Broker Forms

Required only with first case submittal.
The Insurgency Benefits sales agreement is available from your general agent or by email at [email protected].

Vector One Debit-Check Agent/Agency Authorization Form

Loomis Broker Appointment Form

W-9 Form

6 Degrees RBP Set-up Form

Important Notice

Employers should not cancel current coverage until written approval is received from the Underwriter.

The cost of The Secure Plans quoted to a group are based on the information provided to the underwriters at the time the proposal is generated. They are subject to change. Actual costs and eligibility are based on information provided during enrollment. The issuance of a proposal does not guarantee a group will be accepted for coverage. All questions on enrollment forms must be fully and accurately answered. Otherwise. rates may be modified and stop-loss coverage for members making misstatements may be rescinded. This means the plan sponsor (the employer) will be responsible for these claims.

Until written approval is provided to the employer by the underwriter, do not cancel existing coverage.

Personal attention is given to each client’s set-up in the administrator’s various systems (e.g., billing, eligibility). This can take longer than with fully-insured plans.
We strongly encourage submitting enrollment forms prior to the desired effective date.