Register

Search for an

endorsing hospital

Group benefits

for part time and retired

hospital employees

Application Forms

Please call 1-866-768-1477

if you need assistance.

What forms do I need to fill out?

To apply for HCP health benefits you will need to fill out Form 1

Check the list below to see which other forms you also need to fill out.

Please contact us if you have any questions.

Instructions:

- You may fill out the forms online.

- Print out and sign the completed forms and mail them to us

- Don t forget to include your payment

- You may save ONE copy of each completed form for your records.

Note: After you have saved your form, you will not be able to add more information until the form is printed.

Questions:

How do I make my payment?

I am an existing client - how do I make changes to my coverage?

Benefits that work full time for those who don't

FORM 1

Health Care Providers group Enrollment Form

FORM 2

Statement of Health Form

FORM 3

Employees Group

Health Form

FORM 4

Worksheet /Request for Optional Life and Long Term Disability Coverage

FORM 5

Request for Optional Group Life for a Spouse

FORM 6

Request for Optional Group Life for a Child

60 Day offer form

Any applicant required to show evidence that they are applying within 60 days of hire, retirement, full-time transfer etc. must complete this form

(Certain conditions and exemptions apply—see pg.8 for definition of 60 Day Window)

PLAN 1 APPLICANTS ONLY

Any applicant who chooses to apply for Child Life insurance.

PLAN 1 APPLICANTS ONLY

Any applicant who chooses to apply for Spousal Life insurance.

PLAN 1 APPLICANTS ONLY

Any applicant who chooses to apply for Optional or Additional Life and/or Long Term Disability coverage must complete this worksheet.

Any applicant to whom ONE OR MORE of the following

applies must complete this form:

1. You do not work at an endorsing hospital

2. You are not applying in a 60 Day Window

3. You have chosen to apply for any Optional or Additional Life insurance or

Long Term Disability Coverage

Any applicant wishing to be considered for a LEVEL of Health Care coverage which would be an increase to the coverage he or she may be guaranteed to receive, must complete this form.

ALL applicants must complete this form.