UHC Forms and Applications PDF

This page gives you immediate access to Small Group Health Insurance Forms and Applications for California.

UHC Forms & Applications For Small Groups - California
< Go Back OR view forms & apps for: Aetna \| American Fidelity \| Anthem Blue Cross \| Blue Shield \| California Choice \| coPower \| First Horizon \| The Hartford \| Health Net \| HSA Bank HSA California \| Kaiser \| Kaiser Choice Solution \| New Dental Choice \| Premier Access \| Sharp \| Sterling HSA \| The Standard \| UHC / PacifiCare \| Unum Western Health Advantage
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Select a SubCategory... Group Medical \| Dental \| Life & Disability \| Vision
Company	Group Medical - EMPLOYEE	Description	Form #	Rev Date	Fillable
UHC	Employee Enrollment Form & Waiver of Coverage		PCA360949	3-09	Yes
UHC	Enrollment Form - groups over 50 employees	For groups over 50 employees	400-2572	08-06
UHC	Employee Enrollment Form for CA Groups Over 50 Employees		400-2572	10-05
UHC	Employer Health Addendum for CA Groups Up to 50		400-2756	03-06
UHC	Employee Enrollment Form for Additional Dependents for All Fully Insured Groups		100-5221	09-06
UHC	Accidental Dismemberment Statement of Claim for Benefits Form		042-1043	10-05
UHC	Claimant Statement for STD and LTD
UHC	Customer Issue Submission Form		100-7177	06-06
UHC	HRA Worksheet		M39386	06-06
UHC	Health Claim Form		MB4296-GRN	N/A
UHC	Health Statement Application		400-2757	3-09	Yes
UHC	Life Beneficiary Designation Form		042-1013	11-06
UHC	Life Notice of Claim Accelerated Benefit		042-1205	10-05
UHC	Life Disability PRIME EOI Form for Enrollees and Dependents		655-1599	10-07
UHC	Enrollment Application/Change/Cancellation Request		400-2572	08-06
UHC	Pharmacy Reimbursement Claim		100-7297	05-06
UHC	Medicare Change Status Enrollees and Dependents		N/A	N/A
Company	Group Medical - EMPLOYER	Description	Form #	Rev Date	Fillable
UHC	Employer Application		400-3269	3-09	Yes
UHC	Joint Health and Life Employer Application		400-2755	04-06
UHC	Group Acceptance / Change Form		400-3358	7-09	Yes
UHC	Independent Contractors Form		1099	12-05
UHC	Statement of Claim Accident Dismemberment		042-1043	10-05
UHC	Common Ownership Form for Groups Up to 50		N/A	03-06
UHC	Customer Request for Alternative Renewal Quotes Groups Up to 50		N/A	03-04
UHC	HRA Enrollment Worksheet		M39386	06-06
UHC	Direct Debit Authorization Form		PCA325730-000	06-07
UHC	Employer Health Addendum for CA Groups up to 50		400-2248	03-06
UHC	Employer eServices Registration Form for External Use		N/A	N/A
UHC	Disclosure Authorization Form		AUTH-UNI-011504	N/A
UHC	HRA Bank Change Form		100-6809	01-07
UHC	HRA Benefit Form		100-6808	01-07
UHC	Health Insurance Claim Form		N/A	N/A
UHC	Medicare Status Change Form for Enrollees and Dependents		N/A	N/A
UHC	Online Payment Remittance Form		N/A	N/A
UHC	Prescription Drug Reimbursement Claim Form		100-7297	05-06
UHC	Scheduled Direct Debit Authorization Form for Fully insured Groups 1-150		100-8513 PRIME	02-08
UHC	Scheduled Direct Debit Authorization Form for Fully insured Groups 150plus		100-8513 ACIS	02-08
UHC	Select HRA Application Group Size 2-99		N/A	N/A
UHC	CA SB Product and Benefit Selection Form (Effective 7-1-07)		400-2812	07-07
UHC	Product Benefit Selection Form - Calif. SB (Effective 3-1-08)		400-2812	3-08	Yes
UHC	Health Statement Form		400-2757	11-06
Company	Group Medical - OTHER	Description	Form #	Rev Date	Fillable
UHC	Scheduled Direct Debit Authorization Form for Fully insured Groups 1-150		100-8513 PRIME	02-08
UHC	Scheduled Direct Debit Authorization Form for Fully insured Groups 150plus		100-8513 ACIS	02-08
UHC	HRA Benefit Form		100-6808	01-07
UHC	Pharmacy Reimbursement Claim		100-7297	05-06
UHC	Compensation Assignment Form and Instructions		N/A	N/A
UHC	Copy of PRIME New Business 2-99 Enrollment Spreadsheet		N/A	06-07
UHC	Direct Deposit Form and Instructions		N/A	N/A
UHC	Health Insurance Claim		HCFA-1500	12-90
UHC	HRA Worksheet		M39386	06-06
UHC	Medicare Change Status Enrollee		N/A	N/A
UHC	Change Request		PC3304-009	04-04
UHC	Direct Debit Authorization Form		PCA325730-000	06-07
UHC	ProcessWorks Inc. HRA Application		N/A	N/A
UHC	United Advantage Agency Administrator Add/Removal for Agency Principals/Owners		N/A	N/A
UHC	United eServices Agency Administrator Add/Removal for Agency Principals/Owners		N/A	N/A
Select a SubCategory... Group Medical \| Dental \| Life & Disability \| Vision
Company	Dental		Form #	Rev Date	Fillable
UHC	Employee Dental Enrollment Form		100-2659	10-05	Yes
UHC	Employer Dental Application		D-APP-CA	9-05	Yes
UHC	Dental Claim Form		100-2414	03-03	Yes
Company	Life Insurance		Form #	Rev Date	Fillable
UHC	Disability and Life uBuy Employer Application UHIC Trust		LASD-APP	05-03
UHC	Life Beneficiary Form		042-1013	11-03
UHC	Life Notice of Claim Form		042-1205	10-05
UHC	Life and Disability EOI Form for CA Groups 2-99		655-1599	10-07
Company	Vision		Form #	Rev Date	Fillable
UHC	N/A

< Go Back OR view forms & apps for: Aetna \| American Fidelity \| Anthem Blue Cross \| Blue Shield \| California Choice \| coPower \| First Horizon \| The Hartford \| Health Net \| HSA Bank HSA California \| Kaiser \| Kaiser Choice Solution \| New Dental Choice \| Premier Access \| Sharp \| Sterling HSA \| The Standard \| UHC / PacifiCare \| Unum Western Health Advantage