Thank you for your interest in SelectHealth. Our local sales team is here to assist you with the application process.
The following items must be submitted when applying for healthcare coverage:
- A completed Group Data Summary signed and dated by the employer and agent/broker.
- Completed and signed Group Application(s), including Medical and Dental (if applicable).
- A signed Payment Authorization, if applicable.
- Rates quoted assume preauthorized banking withdrawal. If this option is not elected, add a $25 monthly administration fee to the monthly premium.
- A completed, signed, and dated Utah Small Employer Health Insurance Application and Supplement Form or Waiver Form for each employee, including employees in a new hire waiting period.
- Each employee who elects an HSA on the Application Supplement Form must submit a completed, signed, and dated Health Savings Account Enrollment and Authorization to Disclose Health Information form.
- A copy of the most recent billing with current carrier (listing covered employees) or other verification of each employee’s length of time on prior plan (e.g., Certificates of Creditable Coverage), if applicable.
- A check for the estimated first month’s premium amount.
- A copy of the Employer’s Quarterly Wage List (Utah Department of Workforce Services – Unemployment Insurance).
- A copy of the previous month’s payroll records, including hours worked.
- A copy of the business license and/or filed articles of incorporation subject to Underwriting’s request.
Note: You must submit the employer through Broker Exchange prior to mailing the forms to SelectHealth.
Coverage is not in effect until you have received written notice from us, and we reserve the right to determine the effective date of coverage.
Applications older than 60 days that have not been accepted must be resubmitted.
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