Large group submission
Large group plans are available in:
Brown, Calumet, Door, Fond du Lac, Green Lake, Jefferson, Kenosha, Kewaunee, Manitowoc, Marinette, Marquette, Menominee, Milwaukee, Oconto, Outagamie, Ozaukee, Racine, Shawano, Sheboygan, Walworth, Washington, Waukesha, Waupaca, Waushara, and Winnebago counties.
Adams, Ashland, Barron, Bayfield, Buffalo, Burnett, Chippewa, Crawford, Douglas, Dunn, Eau Claire, Grant, Jackson, Juneau, La Crosse, Monroe, Pepin, Pierce, Polk, Richland, Rusk, Sauk, St. Croix, Trempealeau, Vernon, and Washburn counties.
Complete paperwork for an underwritten rate includes:
- A Proposal Request Form
- Complete Employer Census (age or date of birth, gender, election type, zip code)
- Health Tradition Health Questionnaire or 2 Years of Claim Experience
- Current Summary of Benefits and Plan Design
Information required for final large group benefit set-up:
- Large Employer Group Application
- Member Enrollment Form for each eligible employee electing coverage or waiving coverage. The form contains a Waiver Section on page 2; any eligible employee waiving coverage must complete and sign the waiver section (Ins 8.60, Wis. Adm. Code)
- Most recent Wage & Tax statement with notes of terminated, part-time and/or seasonal workers. If no Wage & Tax statement, copies of W2’s or Income Tax return. (Ins. 8.65, Wis. Adm. Code)
- First month’s premium.
Submit all required materials to:
45 Nob Hill Road
Madison, WI 53713