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Large Group Application/Change Form (Medical/Vision: 101+ Full time Equivalent Employees) (Dental: 51+ Full time Equivalent Employees) Thank you for choosing Empire Blue Cross (Empire). Please fill
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Obtain a copy of the large group applicationchange form from the appropriate source.
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Read the instructions carefully to ensure that you understand the requirements.
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Fill in the necessary information on the form, such as the name of the group, contact details, and any other requested information.
04
Provide any supporting documents or attachments as specified in the instructions.
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Submit the completed form to the designated office or organization as indicated in the instructions.
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Who needs large group applicationchange form?

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Any individual or organization that needs to change or update information for a large group, such as a membership organization, corporate entity, or educational institution, may need to use the large group applicationchange form.
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The large group application/change form is a document used to request changes to a large group health insurance plan.
Employers with a large group health insurance plan are required to file the large group application/change form.
To fill out the large group application/change form, employers must provide information about the requested changes to the health insurance plan and submit the form to the appropriate insurance provider.
The purpose of the large group application/change form is to request changes to a large group health insurance plan, such as adding or removing coverage for employees.
The large group application/change form must include details about the requested changes to the health insurance plan, as well as information about the employer and employees covered under the plan.
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