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Forms

Medicare Secondary Payer Form
Agent of Record Assignment Form

Small Group Forms

Medical-Minnesota

2018 Employer Application
2017 Employer Application (11393)
Existing small group employer questionnaire
Controlled Group Form
Affidavit of Ownership and Hours Worked
Submission Checklist
Tax Documentation Guidelines
Seasonal Industry Employee Agreement Form
2018 MN/WI Employee Application or Mid-Year Hires
2017 MN/WI Employee Application or Mid-Year Hires (11366)
MN/WI Change Form (11448)
Coordination of Benefits Claims Form
Domestic Partner Coverage Policy 

Medical-Wisconsin

2018 Employer Application
2017 Employer Application (11394)
Existing small group employer questionnaire
Controlled Group Form
Affidavit of Ownership and Hours Worked
Tax Documentation Guidelines
2018 MN/WI Employee Application or Mid-Year Hires
2017 MN/WI Employee Application or Mid-Year Hires (11366)
Employee Application_Non-ACA (8062)
MN/WI Change Form (11448)
Coordination of Benefits Claims Form

Large Group Forms

Medical-Minnesota and Wisconsin

Proposal Request and Employer Questionnaire
2018 MN Non-Reform and EZ Employer Group Application (15916)
2018 WI Non-Reform and EZ Employer Group Application (15917)
2017 MN Non-Reform and EZ Employer Group Application (11515)
2017 WI Non-Reform and EZ Employer Group Application (11516)
MN/WI Employee Application_ Health History (11518)
Medical Enrollment Form_Open Access_NationalONE (490018)
MN/WI Change Form (11448)
Claim Form (4601)
Coordination of Benefits Claims Form

FSA and HRA Forms

Flexible Spending Account Enrollment/Election Form
Direct Deposit Form
Automatic Claims Submission Opt Out Form
Mid-year Enrollment/Change Form
Letter of Medical Necessity
Health Care Expense Claim Form
Dependent Care Expense Claim Form
Transportation and Parking Expense Claim Form

Dental Plan Forms

Dental MN SG Employer Application_Dental (790005)
Dental Enrollment Form_Open Access (790003)
Dental Enrollment Form_Dental Options (790006)
Dental Enrollment Form_Voluntary (790004)
Combined Med_Dental Enrollment Form_Voluntary (5330)
Combined Med_Dental Enrollment Form (490033)
Dental Coordination of Benefits Form (1643)

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