Resource Center

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2018 Resources

2018 Applications can be found below. For a full array of other important broker materials for 2018, please visit our 2018 Brokers Microsite.

2018 Applications

2018 Large Group Application
2018 Small Group Application
2018 Employee Enrollment Form | Spanish

All HMO Group Applications must also complete the following Disclosure Form.

2018 Large Group HMO Plans

2018 Select 001 HMO
2018 Select 002 HMO
2018 Select 500-80 HMO
2018 Select 1000-80 HMO
2018 Select 1500-80 HMO
2018 Select 2000-80 HMO
2018 Select 2000-100 HMO
2018 Select 2500-80 HMO
2018 Select 3000-80 HMO
2018 Select 3000-100 HSA HMO
2018 Select 4000-80 HMO
2018 Select 5000-80 HMO
2018 Select 5000-100 HSA HMO
2018 Select 6550-100 HSA HMO
2018 Select 6600-100 HMO

2018 Large Group PPO Plans

2018 Select 1000-80 PPO
2018 Select 1500-80 PPO
2018 Select 2000-80 PPO
2018 Select 2500-80 PPO
2018 Select 3000-80 HSA_PPO
2018 Select 3000-80 PPO
2018 Select 5000-80 HSA_PPO
2018 Select 5000-80 PPO
2018 Select 6550-100 HSA PPO
2018 Select 6600-100 PPO

2018 Large Group COC and EOC

2018 Certificate of Coverage - Large Group
2018 Evidence of Coverage - Large Group

2018 Small Group HMO Plans

2018 Select Bronze 6850 HMO
2018 Select Silver 002 HMO
2018 Select Silver 3000 HMO
2018 Select Silver 3000 HSA HMO
2018 Select Gold 001 HMO
2018 Select Gold 1000 HMO
2018 Select Gold 1500 HMO
2018 Select Gold 2000 HMO
2018 Select Platinum 500 HMO

2018 Small Group PPO Plans

2018 Select Gold 2000 PPO

2018 Small Group COC and EOC

2018 Certificate of Coverage - Small Group
2018 Evidence of Coverage - Small Group

2017 Individual Applications

2017 Individual HMO Application | Spanish
2017 Individual PPO Application | Spanish

2017 Individual Brochures

2017 Individual Plans Overview

2017 Individual and Family HMO Plans

Bronze 6550 H.S.A. HMO | Spanish
Bronze 6850 HMO | Spanish

Silver 4500 HMO | Spanish

Gold 001 HMO | Spanish
Gold 1000 HMO | Spanish
Gold 2500 HMO | Spanish

2017 Individual and Family PPO Plans

Silver 2850 H.S.A. PPO | Spanish
Silver 4500 PPO | Spanish

2017 Small and Large Group Brochures

Large Group HMO Plan Overview
Large Group PPO Plan Overview

Small Group HMO Plan Overview
Small Group PPO Plan Overview

2017 Small Group Applications

Small Group HMO Employee Application | Spanish
Small Group HMO Employer Application

Small Group PPO Employee Application | Spanish
Small Group PPO Employer Application

2017 Large Group Applications

Large Group HMO Employee Application | Spanish
Large Group HMO Employer Application

Large Group PPO Employee Application | Spanish
Large Group PPO Employer Application

2017 Small Group HMO Plans

2017 HMO Select Bronze 6550 HSA | Spanish
2017 HMO Select Bronze 6850 | Spanish
2017 HMO Select Silver 002 | Spanish
2017 HMO Select Silver 3000 | Spanish
2017 HMO Select Silver 4000 HSA | Spanish
2017 HMO Select Gold 001 | Spanish
2017 HMO Select Gold 1500 | Spanish
2017 HMO Select Gold 2000 | Spanish

2017 Small Group PPO Plans

2017 PPO Select Bronze 5000 HSA | Spanish
2017 PPO Select Bronze 6550 HSA | Spanish
2017 PPO Select Bronze 6850 | Spanish
2017 PPO Select Silver 3000 | Spanish
2017 PPO Select Silver 4000 HSA | Spanish
2017 PPO Select Silver 4500 | Spanish
2017 PPO Select Silver 5000 | Spanish
2017 PPO Select Gold 1000 | Spanish
2017 PPO Select Gold 1500 | Spanish
2017 PPO Select Gold 2000 | Spanish
2017 PPO Select Gold 2000-3500 | Spanish
2017 PPO Select Gold Copay | Spanish
2017 PPO Select Platinum 500 | Spanish

2017 Large Group HMO Plans

2017 HMO Select 001 | Spanish
2017 HMO Select 002 | Spanish
2017 HMO Select 2000-100 | Spanish
2017 HMO Select 3000-100 HSA | Spanish
2017 HMO Select 3000-80 | Spanish
2017 HMO Select 5000-100 | Spanish
2017 HMO Select 6550-100 HSA | Spanish
2017 HMO Select 6600-100 Standard | Spanish

2017 Large Group PPO Plans

2017 PPO Select 002 | Spanish
2017 PPO Select 500-80 | Spanish
2017 PPO Select 1000-80 | Spanish
2017 PPO Select 1500-80 | Spanish
2017 PPO Select 2000-100 | Spanish
2017 PPO Select 2000-80 | Spanish
2017 PPO Select 2500-70 | Spanish
2017 PPO Select 2500-80 | Spanish
2017 PPO Select 3000-100 | Spanish
2017 PPO Select 3000-100 HSA | Spanish
2017 PPO Select 3000-80 | Spanish
2017 PPO Select 3000-80 HSA | Spanish
2017 PPO Select 5000-100 | Spanish
2017 PPO Select 5000-100 HSA | Spanish
2017 PPO Select 5000-70 | Spanish
2017 PPO Select 5000-80 HSA | Spanish
2017 PPO Select 6550-100 HSA | Spanish
2017 PPO Select 6600-100 Standard | Spanish
2017 PPO Select Standard Copay | Spanish

Additional Submission Forms

Late Submission Form
Deductible Credit Form
Employee Termination Form
Employee Verification Form
Cobra and Medicare Survey
Group Data Submission Agreement

2017 Policy and Plan Coverage Documents

Small Group PPO Certificate of Coverage
Small Group Evidence of Coverage
 
Large Group PPO Certificate of Coverage
Large Group Evidence of Coverage

Individual PPO Policy
Individual Evidence of Coverage

Successful Returns©

Successful Returns Fact Sheet
Outcomes
Directions to the Facility

WorkLink©

WorkLink Fact Sheet
Quick Reference Guide
Providers Process Guide
Work Status Form
Pre-Authorization Form

Nonsubscribers

Texas Department of Insurance; Division of Workers' Compensation
Texas Association of Responsible Nonsubscribers (TXANS)

Longshore

Department of Labor (DOL)
DOL Longshore First Report of Injury
DOL Division of Longshore & Harbor Workers' Compensation (DLHWC)
Longshore FAQ