Simmons Benefit Group Inc.

Serving Life & Health Insurance Agents Nationwide

The Grand Teton Mountain Peaks

Insurance Products

Individual Health Health Savings Account(HSA) HSA Calculator Individual Life Group Insurance Group Forms Accident Plans Senior Benefits Short Term Medical Dental & Vision International Health Insurance

Client Access

Agents

Agent Access Affordable Care Act

Group Forms

Carrier	Form Number	Title	Pg.	Use
(All)	ISE-APP-8-2007	Idaho Small Employer Application	4	Standard Application form for employees
Assurant	50100 (Rev. 9/2007)	Employer Participation Agreement/Application	4	To enroll small groups
	28616-ID (Rev. 4/2006)	Idaho Group Insurance Employee Enrollment Form	5	To enroll individual employees
	Blue Cross	3-468 (03-02) Employee Census Data	2	To enroll small groups
3-469 (06-08)	Group Questionnaire for New Groups 2-50 Employees	4	To enroll small groups of 2-50 employees
3-470 (06-08)	Application for Small Employer Coverage	1	To enroll small groups (employer form)
Primary Health	SHBAPP 07/08	Employer Application	4	To enroll small groups
Primary Health	ISE-APP-12/2000	Idaho Small Employer Application	4	To enroll individual employees in a group
Regence BlueShield	5200ID (Rev. 4/08)	Group Master Application	4	To enroll small groups
Fidelity Security Life	NexStep20082.pdf	NexStep Product Brochure	12	Get familiar with the product
	Procedure for Completing Appointment Application		1	How to get appointed with FSL
	NexStep FSL Agent Data Sheet		1	Appointment Form for FSL
	Cat. No. 20479P	Instruction for the Requester of Form W-9	1	Instructions for W-9 Requestor
	W-9 (Rev. 1-2003)	Instruction for the Requester of Form W-9	4	Request TIN
	NBSF, A-01027, A-01026	NexStep New Business Kit	7	Group application forms
	A-01026	NexStep Policy Enrollment Form	1	Policy Enrollment form
	Single Case Agreement		2	Commissions form
	STD 02/20007	NexStep Hospital Confinement Indemnity (GAP) Claim Form	2	Form for all claims