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Find a Form

View and print administrative forms based on your group size and location.
Please choose the state where your company's headquarters is located.

Iowa

Large Group Forms

Enrollment/Change/Cancellation Form (PDF)
Enrollment/Change/Cancellation Form (Spanish) – (PDF) 

Small Group Forms

Small Employer Group Application (PDF)
Enrollment/Change/Cancellation Form (PDF)
Enrollment/Change/Cancellation Form (Spanish) – (PDF) 

Minnesota

Large Group Forms

Plans with a six-digit group number:

Enrollment/Change/Cancellation Form

Plans with a five-digit group number:

Group Enroll / Change / Cancellation Form (writeable PDF)
 Group Enrollment / Change / Cancellation Form (Spanish)
 Plan Selection Change Form
Plan Selection Change Form (Spanish)
Scheduled Direct Debit Authorization Form for Groups

Small Group Forms

Small Employer Group Application (PDF)
Group Enroll / Change / Cancellation Form (writeable PDF)
Plan Selection Change Form
Plan Selection Change Form (Spanish)
Scheduled Direct Debit Authorization Form for Groups
Small Group Enrollment / Change / Cancellation Form (Spanish) 

Nebraska

Large Group Forms

Enrollment/Change/Cancellation Form (PDF)
Enrollment/Change/Cancellation Form (Spanish) – (PDF)

Small Group Forms

Small Employer Group Application (PDF)
Enrollment/Change/Cancellation Form (PDF)
Enrollment/Change/Cancellation Form (Spanish) – (PDF)

North Dakota

Large Group Forms

Plans with a six-digit group number:
Enrollment/Change/Cancellation Form

Plans with a five-digit group number:
Group Enroll / Change / Cancellation Form (writeable PDF)
Group Enrollment / Change / Cancellation Form (Spanish)
Plan Selection Change Form
Plan Selection Change Form (Spanish)
Scheduled Direct Debit Authorization Form for Groups 

Small Group Forms

Group Enroll / Change / Cancellation Form (writeable PDF)
Plan Selection Change Form
Plan Selection Change Form (Spanish)
Scheduled Direct Debit Authorization Form for Groups
Small Group Enrollment / Change / Cancellation Form (Spanish) 

South Dakota

Large Group Forms

Plans with a six-digit group number:
Enrollment/Change/Cancellation Form

Plans with a five-digit group number:
Group Enroll / Change / Cancellation Form (writeable PDF)
Group Enrollment / Change / Cancellation Form (Spanish)
Plan Selection Change Form
Plan Selection Change Form (Spanish)
Scheduled Direct Debit Authorization Form for Groups 

Small Group Forms

Group Enroll / Change / Cancellation Form (writeable PDF)
Plan Selection Change Form
Plan Selection Change Form (Spanish)
Scheduled Direct Debit Authorization Form for Groups
Small Group Enrollment / Change / Cancellation Form (Spanish) 

Wisconsin

Large Group Forms

Plans with a six-digit group number:
Enrollment/Change/Cancellation Form

Plans with a five digit group number:
Group Enroll / Change / Cancellation Form (writeable PDF)
Group Enrollment / Change / Cancellation Form (Spanish)
Plan Selection Change Form
Plan Selection Change Form (Spanish)
Scheduled Direct Debit Authorization Form for Groups 

Small Group Forms

Group Enroll / Change / Cancellation Form (writeable PDF)
Plan Selection Change Form
Plan Selection Change Form (Spanish)
Scheduled Direct Debit Authorization Form for Groups
Small Group Enrollment / Change / Cancellation Form (Spanish)
WI Small Group Uniform Application

Employer Service Center

For groups headquartered in Minnesota, North Dakota, South Dakota and Wisconsin:
1-800-936-6880

For groups headquartered in Iowa and Nebraska:
1-866-894-8052

Monday – Friday: 8 a.m. - 5 p.m. CT
Closed 8 a.m. - 9 a.m. Thursdays

Email us