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Broker Forms

Click on the links below to find forms that you'll need for many of your EmblemHealth transactions. Follow the instructions specific to each form regarding supporting documents.

• EmblemHealth Large Employer Group Application
  Complete this application before enrolling a large employer group with EmblemHealth.
• EmblemHealth Small Employer Group Application
  Complete this application before enrolling a small employer group with EmblemHealth.
• Health Benefits Waiver Form
  This form should be completed by an employee who is declining enrollment in the plan.
• Transaction Form for Group Accounts
  This form should be used for enrolling, terminating or changing the status of a subscriber.
• EmblemHealth Small Group Underwriting Guidelines
• EmblemHealth Large Group Underwriting Guidelines
• ConsumerDirect Sales Kit
  With EmblemHealth's Health Savings Account Program, you can offer your clients an innovative way to take care of their employees and their bottom line. Available for groups with more than 50 employees.
  
• Employee HSA Online E-Application
• Employee HSA Application
• Employer HSA Application

NOTE: The forms on this page are available as Adobe® PDF files. You will need Adobe Reader®, a free program from Adobe, to download and print the forms. Click here to get Adobe Reader now. Follow Adobe's instructions for download and installation. Print out the appropriate form and mail it to the address listed on the form.