Medical Certificate

Individual New Business Medical Certificate

Member Handbook

Employee Census Form

Small Employer Uniform Employee Application for Group Health Insurance - for prospective groups (Word Document, complete online)

Small Employer Uniform Employee Application for Group Health Insurance - Applying

Small Employer Uniform Employee Application for Group Health Insurance - Waiving

Group Enrollment/Change Form for prospective groups of 51+ employees and for currently enrolled groups

Group Electronic Funds Transfer Authorization/Change Form

Combined Employer Form Health Questionnaire and Employer Group Application (for HMO and POS Coverage)

Small Group Disclosure Forms

Wage & Tax Form

New Small Group Checklist Employer Form Employer Group Application Disclosure Forms Uniform application from each full-time employee applying. (If employee is applying, but waiving spouse or dependent children, sign page 4 of the application. If employee is waiving, fill out only pages 1-4.) Most recent wage & tax Prior carrier bill Check for 1 month's premium Group must be complete and ready to submit to underwriting by the 10th of the month prior to the effective date.

Large Group Forms
(51+ total employees)

Certification of Domestic Partnership

Group Enrollment/Change Form for prospective groups of 51+ employees and for currently enrolled groups

Group Electronic Funds Transfer Authorization/Change Form

Combined Employer Form Health Questionnaire and Employer Group Application (for HMO and POS Coverage)

Health Questionnaire (short form)

Health Questionnaire (long form)

Wage & Tax Form

Waiver Form

Disclosure Form

New Large Group Checklist Employer Form Employer Group Application Disclosure Form Enrollment form from each full-time employee applying. (If employee is applying, but waiving spouse or dependent children, please submit an enrollment form and waiver.) Waiver from each full-time employee waiving coverage. Most recent wage & tax Prior carrier bill Check for 1 month's premium Group must be complete and ready to submit to underwriting by the 10th of the month prior to the effective date.

Non Group Forms
Non Group Enrollment & Change Form
Please send the Non Group Enrollment & Change Form to:
Physicians Plus Insurance Corporation
PO Box 2078
Madison, WI 53701-2078

Health Questionnaire

Authorization for Release of Information

Non Group EFT Authorization & Change Form



Medicare Forms
Medicare Supplement Plan Enrollment Form

Medical Assistance Entitlement and Medicare Supplement Replacement Notice



Disclosure Authorization
Disclosure Authorization Form



Group Administrative Manual
Group Administrative Manual

Got Prescription Drug Coverage? Please Read!
Does your company offer prescription drug coverage to Medicare- and Medicare Part D-eligible employees? To help these individuals make informed choices about prescription drug coverage, the Center for Medicare and Medicaid Services says that you must provide them with a notice of creditable or non-creditable coverage by November 15.

Disclosure to CMS Form and Creditable Coverage Guidance and Model Disclosure Notices from the Centers for Medicare & Medicaid Services.