NEW GROUP ENROLLMENT CHECKLIST FOR 2-5 ENROLLING CONTRACTS

Checklist Attached


FULLY INSURED (51-99)


Non-Virgin

1. Completed PGQ form w/ Signature

2. Member Level Census

3. State Mandated Reporting (Claims vs Premium and Large Claim Listing)

4. Summary of Benefits

5. Current invoice


Virgin

1. Completed PGQ form w/ Signature

2. Member Level Census