SeeChange Health Insurance Forms
	Checklist SeeChange Health 2-50 1 Page (Rev. 1/2012)
	Checklist SeeChange Health 51+ 1 Page (Rev. 1/2012)
	SeeChange Health Application Employee (2-50) 4 Pages (Rev. 12-2011)
	SeeChange Health Application Employee (51+) 4 Pages (Rev. 12/2011)
	SeeChange Health Application Employer (2-50) For employer groups with 2-50 employees, 7 Pages (Rev. 2/2012)
	SeeChange Health Application Employer 51+ 6 Pages (Rev. 2/2012)
	SeeChange Health Custodial Parent Verification A non-custodial parent who is under court or administrative order to provide health care coverage to a dependent minor, is required to provide information to SeeChange Health, 1 Page (Rev. 9-2011)
	SeeChange Health Declination Form Complete if your spouse, domestic partner or dependent(s) are refusing your employer’s SeeChange Health Insurance health plan coverage., 1 Page (Rev. 9-2011)
	SeeChange Health Domestic Partnership Affidavit 1 Page (Rev. 1-2012)
	SeeChange Health HIPAA Individual Authorization 2 Pages (Rev. 9-2011)
	SeeChange Health Membership Status/Information Change Form 4 Pages (Rev. 9-2011)
	SeeChange Health Owner/Officer Statement Small Group requirements for proof of eligibility for owners/officers when no DE-6 available or if not listed on DE-6, 1 Page (Rev. 9-2011)
	SeeChange Health Patient Claim Form Please use this form for medical claims only. Do not use for pharmacy claims., 1 Page (Rev. 9-2011)
	SeeChange Health PRESCRIPTION DRUG CLAIM FORM 2 Pages (Rev. 2011)
	SeeChange Health Questionnaire 1 Page (Rev. 9-2011)
	SeeChange Health Statement of Understanding 2-50 Groups: SeeChange Health relies upon the verification made in this statement that no wrap plan will be paired with any SeeChange Health plan, with the exception of the HRA 5000, 2 Pages (Rev. 1/2012)

SeeChange Health Insurance Benefit Plans for 2-50 Employees
	Classic 2200 Plan Summary 2 Pages (Rev. 4-2012)
	Classic 3500 Plan Summary 2 Pages (Rev. 4/2012)
	Classic 5000 Plan Summary 2 Pages (Rev. 4/2012)
	Deluxe 1000 Copay Plan Summary 2 Pages (Rev. 4/2012)
	Deluxe 2000 Copay Plan Summary 2 Pages (Rev. 4/2012)
	Deluxe 3000 Copay Plan Summary 2 Pages (Rev. 4/2012)
	Deluxe 4000 Copay Plan Summary 2 Pages (Rev. 4/2012)
	Deluxe 500 Copay Plan Summary 2 Pages (Rev. 4/2012)
	HRA 5000 Plan Summary 2 Pages (Rev. 4/2012)
	HSA 3000 Plan Summary 2 Pages (Rev. 4/2012)
	HSA 4000 Plan Summary 2 Pages (Rev. 4/2012)
	HSA 5000 Plan Summary 2 Pages (Rev. 4/2012)
	No Deductible 3.0 Plan Summary 2 Pages (Rev. 4/2012)
	No Deductible 6.0 Plan Summary 2 Pages (Rev. 4/2012)
	No Deductible 9.0 Plan Summary 2 Pages (Rev. 4/2012)
	Select 10000 Plan Summary 2 Pages (Rev. 4/2012)
	Select 8000 Plan Summary 2 Pages (Rev. 4/2012)

Be sure you have the latest free version of Acrobat Reader from Adobe. This program will allow you to store and print the forms from your hard drive. If you do not have Adobe Acrobat Reader, click here or on the "Get Acrobat Reader" Image, to download the software.



For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com