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SMALL GROUP APPLICATION/CHANGE FORM (250 eligible employees) www.empireblue.comThank you for choosing Empire. Please fill out all items below and print clearly in black or blue ink in order for us
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01
Obtain the small group applicationchange form from the appropriate source.
02
Carefully read and understand the instructions provided on the form.
03
Fill in your personal information accurately, such as your name, contact details, and any other required details.
04
Provide information about the small group you are applying for a change, including the current group details and the desired changes.
05
Clearly state the reason for requesting the change and provide any supporting documentation if necessary.
06
Review the completed form for any errors or missing information.
07
Sign and date the form in the designated spaces.
08
Submit the filled-out small group applicationchange form to the appropriate authority or department as instructed.
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Keep a copy of the completed form for your records.

Who needs small group applicationchange form?

01
Anyone who is currently part of a small group and needs to request a change in their group arrangement. This may include individuals who want to switch to a different small group, transfer between existing groups, or make modifications to their current small group details.
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The small group application/change form is a document used by small businesses to apply for or modify their health insurance coverage under a small group health plan.
Small businesses that wish to apply for new health insurance coverage or make changes to their existing coverage are required to file the small group application/change form.
To fill out the small group application/change form, businesses must provide their basic information, employee details, and the specific changes they wish to make, ensuring all required fields are completed accurately.
The purpose of the small group application/change form is to provide a structured way for small businesses to apply for or alter their health insurance coverage, ensuring compliance with insurance regulations.
The form typically requires information such as the business name, address, employee count, type of coverage desired, and any specifics related to changes being requested.
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