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2018 Applications can be found below. For a full array of other important broker materials for 2018, please visit our 2018 Brokers Microsite.
2018 Large Group Application2018 Small Group Application2018 Employee Enrollment Form | Spanish
All HMO Group Applications must also complete the following Disclosure Form.
2017 Individual HMO Application | Spanish2017 Individual PPO Application | Spanish
2017 Individual Plans Overview
Bronze 6550 H.S.A. HMO | SpanishBronze 6850 HMO | Spanish
Silver 4500 HMO | Spanish
Gold 001 HMO | SpanishGold 1000 HMO | SpanishGold 2500 HMO | Spanish
Silver 2850 H.S.A. PPO | SpanishSilver 4500 PPO | Spanish
Large Group HMO Plan OverviewLarge Group PPO Plan Overview
Small Group HMO Plan OverviewSmall Group PPO Plan Overview
Small Group HMO Employee Application | SpanishSmall Group HMO Employer Application
Small Group PPO Employee Application | SpanishSmall Group PPO Employer Application
Large Group HMO Employee Application | SpanishLarge Group HMO Employer Application
Large Group PPO Employee Application | SpanishLarge Group PPO Employer Application
2017 HMO Select Bronze 6550 HSA | Spanish2017 HMO Select Bronze 6850 | Spanish2017 HMO Select Silver 002 | Spanish2017 HMO Select Silver 3000 | Spanish2017 HMO Select Silver 4000 HSA | Spanish2017 HMO Select Gold 001 | Spanish2017 HMO Select Gold 1500 | Spanish2017 HMO Select Gold 2000 | Spanish
2017 PPO Select Bronze 5000 HSA | Spanish2017 PPO Select Bronze 6550 HSA | Spanish2017 PPO Select Bronze 6850 | Spanish2017 PPO Select Silver 3000 | Spanish2017 PPO Select Silver 4000 HSA | Spanish2017 PPO Select Silver 4500 | Spanish2017 PPO Select Silver 5000 | Spanish2017 PPO Select Gold 1000 | Spanish2017 PPO Select Gold 1500 | Spanish2017 PPO Select Gold 2000 | Spanish2017 PPO Select Gold 2000-3500 | Spanish2017 PPO Select Gold Copay | Spanish2017 PPO Select Platinum 500 | Spanish
2017 HMO Select 001 | Spanish2017 HMO Select 002 | Spanish2017 HMO Select 2000-100 | Spanish2017 HMO Select 3000-100 HSA | Spanish2017 HMO Select 3000-80 | Spanish2017 HMO Select 5000-100 | Spanish2017 HMO Select 6550-100 HSA | Spanish2017 HMO Select 6600-100 Standard | Spanish
2017 PPO Select 002 | Spanish2017 PPO Select 500-80 | Spanish2017 PPO Select 1000-80 | Spanish2017 PPO Select 1500-80 | Spanish2017 PPO Select 2000-100 | Spanish2017 PPO Select 2000-80 | Spanish2017 PPO Select 2500-70 | Spanish2017 PPO Select 2500-80 | Spanish2017 PPO Select 3000-100 | Spanish2017 PPO Select 3000-100 HSA | Spanish2017 PPO Select 3000-80 | Spanish2017 PPO Select 3000-80 HSA | Spanish2017 PPO Select 5000-100 | Spanish2017 PPO Select 5000-100 HSA | Spanish2017 PPO Select 5000-70 | Spanish2017 PPO Select 5000-80 HSA | Spanish2017 PPO Select 6550-100 HSA | Spanish2017 PPO Select 6600-100 Standard | Spanish2017 PPO Select Standard Copay | Spanish
Late Submission FormDeductible Credit FormEmployee Verification FormCobra and Medicare SurveyGroup Data Submission Agreement
Small Group PPO Certificate of CoverageSmall Group Evidence of Coverage Large Group PPO Certificate of CoverageLarge Group Evidence of CoverageIndividual PPO PolicyIndividual Evidence of Coverage
Successful Returns Fact SheetOutcomesDirections to the Facility
WorkLink Fact SheetQuick Reference GuideProviders Process GuideWork Status FormPre-Authorization Form
Texas Department of Insurance; Division of Workers' CompensationTexas Association of Responsible Nonsubscribers (TXANS)
Department of Labor (DOL)DOL Longshore First Report of InjuryDOL Division of Longshore & Harbor Workers' Compensation (DLHWC) Longshore FAQ