Broker of Record Templates

Please find templates from all carriers regarding BOR changes.

Aetna
CareFirst
Guardian
Hartford
Humana
Lincoln
UHC
General Carrier Transfer
Single Case Amendment

Broker Outsourcing

Resources

Carrier Calendar

January
February
March

COBRA

Administration of Extended Benefits
COBRA and MD State Extension
COBRA State Extension Administrative Services

Contracting & Licensing

This section gives you the information needed to be contracted with GBS and other carriers.

Fully-Insured

Please also provide a copy of your license and E&O showing Cyber Security Insurance and General Commercial Liability and a W-9.

CareFirst FSP/GP Election Form
GBS Business Associate Agreement
GBS Direct Deposit Authorization Form
UHC Producer Credentialing Forms
UHC Producer Credentialing Instructions
Self-Funded

Please also provide a copy of your license and E&O showing Cyber Security Insurance and General Commercial Liability and a W-9.

FSL Agent Data Sheet
FSL Credit Card Form
GBS Sales Agreement

FSA Forms

Claim Form
Eligible Expenses
Employee Guide
Enrollment Forms
Group Application & ACH Form
POP Cafeteria Plan
Reimbursement Forms

GBS University

GBS University Courses

HRA Forms

Group Application & ACH Form
How To Use Your Debit Card
SPD

Large Group Fully-Insured

Enrollment Materials

Carrier Risk Screeners

Aetna 51+ Risk Questionnaire (DC, VA, MD, PA)
Aetna Billing and Collection Agreement
CareFirst DC 51+ Screener FTE and Common Ownership
CareFirst MD 51+ Screener FTE and Common Ownership
CareFirst MD (PG & Montgomery) 51+ Screener FTE and Common Ownership
CareFirst VA 51+ Screener FTE and Common Ownership
Cigna Group Risk Questionnaire
Kaiser Group Risk Questionnaire
UHC DC 51-99 Screener FTE and Common Ownership
UHC DE 51-99 Screener FTE and Common Ownership
UHC MD 51-99 Screener FTE and Common Ownership
UHC PA 51-99 Screener FTE and Common Ownership
UHC VA 51-99 Screener FTE and Common Ownership

RFP Details & Census Templates

Aetna 51-99 RFP Details
Aetna GBS Census Template
CareFirst 51-99 RFP Details
CareFirst GBS Census Template
Cigna 51-99 RFP Details
Cigna GBS Census Template
UHC 51-99 RFP Details
UHC GBS Census Template

Application

GBS Group Application (All Forms)

Large Group Self-Funded

RFP
ASO

Marketing Materials

Brochures
Self-Funded
Technology

Small Group Fully-Insured

Enrollment Materials
Submission Materials

Small Group Self-Funded

Benefit Summaries
Case Submissions
Checklist
Cigna Network
Claims
Marketing & Guides
Underwriting