Empire-Frequently Used Forms

Electronic Debit Initial Payment Form

Waiver Form

Online Payment

Add Change Member Form

Employee Enrollment Form

Handbook For Group Benefit Administrators

Employer Enrollment Form

Cancellation Request Letter

Empire BCBS Frequently Used Forms

Included in here are the 6 most commonly used forms for Empire BCBS Small Group Insurance for the state of New York. Empire BCBS Organization has so many forms, so even as a broker, we sometimes will need time to figure out which form is for what, Hence, we how provided here the 6 most commonly used form here, if there is anything else you need, feel free to leave a comment below or CONTACT US here.

Empire BCBS Electronic funds transfer (EFT Debit) for Small Group.

The Small Group EFT form allows the electronic transfer of money from your company bank account to be Empire BCBS.

Empire BCBS Online Payment Link

This link allows you to make payment online directly, hence saving you the hassle of writing a check and mail it. (Mail do get lost, and in the old days, we always have to remind our clients to cover up the check). Mail with checks tends to misplace most often.

Empire BCBS Employee Enrollment Form

The is the form that requires 2 signatures. One from the Employer, or Employer representative. It can be the HR or group benefits administrator. For multi-partner employers group, By signing this form, it allows Empire BCBS to electronically debit money from your company bank account, hence saving the hassle of forgetting to make payment & check to mail.

Empire BCBS Employer Group Form

This form is used for identifying the Employer Group Information, the Tax ID, Name & Address must match the information on the NYS-45. The NYS-45 Tax Form is almost always required for new group enrollment, except where the group aka company was established less than 3 months ago, hence, have no time to file the NY State mandated employee worker comp & unemployment insurance form.

If you have a group of multiple owners, please CONTACT US to discuss.

Empire BCBS Waiver Form

This is complicated, NY has a 60% participation Ratio

Empire BCBS Add/Change Member Form

This form is used to add a newborn, a newly wedded spouse, dropped a divorce souse & etc

Empire BCBS Handbook For Group Benefit Administrators

Empire BCBS Cancellation Request Letter

The cancellation needed to be done 30 days ahead of time

For other not commonly used forms, click here

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