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Large Group Member Application for Health, Dental, and 2026
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- Click ‘Get Form’ to open the Large Group Member Application in the editor.
- Begin by filling out the Employee Information section. Enter the full name, date of birth, sex, and complete mailing address of the employee. Ensure all contact details are accurate.
- Proceed to the Employer’s Information section. Input the employer's name, federal tax ID number, and address. Specify the type of ownership and business type.
- Injury Details should be filled next. Document the date and time of the accident, along with a detailed description of how it occurred. Include any relevant medical information.
- Complete any additional forms required for medical care authorization or consent for health information disclosure as needed.
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Related links
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Group APP (11/15). Large Group Member Application for. Health, Dental and Vision Insurance. ☐ Other. * Social Security number is requiredRead more
Health Advocate provides employee health advocacy and navigation services that help members resolve billing issues, find providers, understand benefits, and