Forms

eNational Benefits Our Products Services Offered Provider Directory Forms

Forms
Simple downloads of the forms you need

The links below are the forms. To view in your browser, simply "Left-click" on the link. To download and save your hard drive, "Right-click" and select "Save Target As." You will likely need to print out the form you need and fax or mail to us. Please contact us if we can assist you in any way.

Humana
Humana employee enrollment application: 2-9 employees (41 KB)
Humana employee enrollment application: 10-50 employees (41 KB)

Humana employee enrollment application: 51+ employees (44 KB)

Anthem
Enrollment Application 2-19 (177 KB)

Anthem Application 20+ (175 KB)

Aetna
Ohio Enrollment/Change Request (178 KB)

Indiana Enrollment/Change Request (178 KB)

Medical Mutual
Employee Application and Change Form - Groups up to 9 (87 KB)

Employee Application and Change Form - Groups 10+ (87 KB)

MetLife
Small Business Center Change Request (548 KB)

U.S. Life/Amer. General
Application for Group Voluntary Programs(106 KB)

United Healthcare

UHC enrollment form Ohio Groups 2-9 employees (50 KB)
UHC enrollment form Ohio Groups 10-50 employees (46 KB)

UHC enrollment form Ohio Groups 51+ employees (45 KB)

Hartford Insurance
Hartford Enrollment Form for all coverages(117 KB)

Dental Care Plus

Dental Care Plus Group Enrollment Form (19 KB)
Dental Care Plus Voluntary enrollment RForm (19 KB)

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