This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
- Employer Application
Current Dental Carrier Billing (for companies with 10+ eligible who are electing Dental EPO, PPO or Indemnity).
Submit copy of current billing statement and statement from 12 months prior in order to waive the waiting period for major services (statement from 24 months prior required for Orthodontic – must show Orthodontic coverage). May not apply to all carriers.
Minimum Premium Deposit Check:
For case submission, employer may submit a copy of the group’s premium check payable to Choice Builder for the original quoted premium (add an additional one-time fee of $100 for Section 125).
Section 125 (POP) – Add an additional $100 one-time fee to the premium deposit.
COBRA premium is not required, but if submitted, include a separate check from the employer or COBRA enrollee payable to: Choice Builder.
- Employee Enrollment Application - Effective 5/1/2019 (and dependent waivers, if dependents not enrolling)
- Employee Change Request Form - Effective 5/1/2019
Disabled Dependent Certification
– Must be completed for dependent child(ren) over the eligibility age and not a full-time student.
First Case only – (required for broker(s) signing the Employer Application
- Case Submission Acknowledgement
- Required anytime a case is submitted to Choice Builder on or after the requested effective date. Disclaimer to members stating that they will not receive ID cards or other materials on time, and that it may take some time to show up in the carrier's system. Not required if case is submitted well ahead of time.
- CB Initial Payment Form (One-Time ACH)
|After approval, prior carrier termination letter must be submitted by the employer or broker.|
For other useful or older documents, please refer to the Forms database.