Forms & Resources

Agent Forms & Resources

Use this information hub to submit information via DocuSign, access forms and other resources for doing business.

General Resources

Agents

Agent Compensation Schedule

Agent Checklist for Prescreens and Sold Groups

Use this checklist to ensure you have the required documents in place to expedite the processing of your prescreen or sold group.

Writing Agent Transmittal – Single Agent Commission

Writing Agent Transmittal – Submit Split Agent Commission

For Employers

Employer Death Claim

Employer Disability Claim

Billing Adjustment Worksheet

Employer Portal Authorized Access

Complete and submit this information as your group’s authorized representative to have access to the Employer Portal.

Request for Appointment of Personal Representative Form

Plan Members must complete this information to release PHI to a provider or other party.

SafeGuard logo

General Resources

Group Setup Form

ACH Processing Form

Illinois Resources

Employee Enrollment Form

Employer Disclosure Form

Employee Short Medical Form

Employee Waiver Form

Indiana / Ohio Resources

Employee Enrollment Form

Employer Disclosure Form

Employee Short Medical Form

Employee Waiver Form

Michigan Resources

Employee Enrollment Form

Employer Disclosure Form

Employee Short Medical Form

Employee Waiver Form

Wisconsin Resources

Employee Enrollment Form

Employer Disclosure Form

Employee Short Medical Form

Employee Waiver Form

AHCN Coverage Resources

Group Setup Form

ACH Processing Form

Employer Disclosure Form

Employee Addendum to Employer Disclosure

Large Group Insured

Michigan Resources

Employer Large Group Application

Employee Enrollment Form

Metal Plans

Michigan Resources

Employer Group Application

Employee Enrollment Form

Ohio Resources

Employer Group Application

Employee Enrollment Form

Wisconsin Resources

Employer Group Application

Small Group Employer Uniform Employee Application

Indiana Resources

Employer Group Application

Employee Enrollment Form