Forms

View or print all the forms you’ll need to do business with AvMed.

Appointment Forms

• Application for Agent Appointment
• Direct Deposit Authorization Form
• IRS W-9
• Individual Producer Agreement
• Commercial Group Agent Agreement
• Copy of Errors & Omissions (E&O)
• Copy of Florida insurance license

Small Group Forms

• Appointment of Representative (Group members)
• Employee Status Change Form (English)
• Employee Status Change Form (Español)
• Employee Enrollment Form (English)
• Member Disclosure Form
• Pharmacy Transition of Medications
• Waiver of Coverage
• Employer Risk Questionnaire
• Medical Transition of Care
• HIPAA Plan Sponsor Certification Form

• Continuation of Coverage (mini-cobra)
• Common Ownership Form
• COBRA form English
• COBRA form Spanish
• Contractor Relationship - 1099 Affidavit  (Word template)
• Creditable Coverage Form
• Employee Census
• Employer Risk Questionnaire (Required for groups of 10-50)
• PEO Questionnaire Form
• Individual Medical Questionnaire (Required for groups of
  1-9; Optional for groups of 10-50)
• Small Group Master Application
• Small Group Submission Deadline Calendar 2012
• Small Group Underwriting Guidelines
• Small Group Checklist

Large Group Forms

• Appointment of Representative (Group members)
• Employee Status Change Form (English)
• Employee Status Change Form (Español)
• Employee Enrollment Form (English)
• Member Disclosure Form
• Pharmacy Transition of Medications
• Waiver of Coverage
• Employer Risk Questionnaire
• Medical Transition of Care
• HIPAA Plan Sponsor Certification Form

• COBRA form English
• COBRA form Spanish
• Large Group Submissions Checklist
• Large Group Commission Rate Agreement Form
  
• Self-Funded Group Enrollment Form
• Large Group Underwriting Guidelines

Individual Forms

• Application PDF
• Underwriting Pre-Screening Form