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Forms & Benefits

Enrollment Information and Forms

  1. Quote Request Form
    (Use for obtaining a quote from Q&A Insurance Marketing)
  2. 2017 CBX Benefit Book
    (Includes an overview of the current CBX benefit portfolio as well as rates and enrollment guidelines)
  3. 2017 Participation Agreement
    (Employer Application for all size firms – one application regardless of the number of plans you choose)
  4. 2017 Landmark Chiro Census Add Form
    (For existing CBX participating firms to provide employee and dependent data needed to enroll in chiro/acu coverage)
  5. Employee Application (Dental / Vision / Chiro / LifeLock / CADR+ / MetLaw)
    (All enrolling employees must complete this form. Employees waiving group coverage must complete the Declination section)
  6. Unum Life Enrollment Form
    (For employees enrolling in either group (employer paid) term life or voluntary term life products)
  7. Unum Evidence of Insurability Form
    (Used when applying for amounts in excess of non-medical maximum or when applying outside of the Initial Offering)
  8. Unum Beneficiary Designation Form

Related Forms

  1. Employee Termination Form
  2. Employee Change Form
    (Use to make changes to existing employee information)
  3. Open Enrollment Change Form
    (Use to make change to your firm’s group offering during open enrollment)
  4. Domestic Partner Affidavit

Claim Forms

  1. Met Life Dental Claim Form
  2. VSP Vision Out of Network Claim Form
  3. BVV OON Claim Form

Carrier Evidences of Coverage (EOCs)

MetLife Dental

  1. Premier Dental Plan with Ortho
  2. Premier Dental Plan
  3. Standard Dental Plan with Ortho
  4. Standard Dental Plan
  5. Savings Plus Dental Plan
  6. Dental HMO MET150A
  7. Voluntary Dental Plan

VSP Vision

  1. High Vision Plan
  2. High Vision Plan with Protec
  3. Low Vision Plan
  4. Low Vision Plan with Protec
  5. High Materials Only Plan
  6. High Materials Only Plan with Protec
  7. Low Materials Only Plan
  8. Low Materials Only Plan with Protec

Anthem Blue Cross

  1. Voluntary Blue View Vision

Unum Life

  1. Basic Term Life Certificate of Insurance
  2. Optional Term Life Certificate Booklet
    (Benefit Solutions will send the accompanying Confirmation of Coverage letter to the employee’s home address once coverage is approved)

Landmark Healthplan

  1. Standard Chiropractic
  2. Expanded Chiropractic
  3. Standard Combined Chiropractic & Acupuncture
  4. Expanded Combined Chiropractic & Acupuncture