health insurance new group requirements

For enrollment purposes, the following forms must be received 30 days prior to the requested effective date both fully completed and signed.

Send to Business Resource Services:

  1. BRS Membership Form [PDF 36K]
  2. BRS/BCBS Enrollment Agreement(Click Here)
  3. Check for membership fee made payable to "Business Resource Services" (see membership form for rates)

Send to:
Business Resource Services
Attn: Tom McKeown
P.O Box 9367
South Burlington,VT 05407-9367

*Brokers must also submit Completed and signed Single Case Agreement

Download BRS forms as PDF files. PDF requires the free Adobe Acrobat Reader® [Download Now]

Send to Blue Cross and Blue Shield of Vermont:

  1. Group Enrollment Form (application) for each employee [PDF 808K]
  2. Small Group Certification/Employee Census Form [PDF 144K]
  3. BRS/BCBS Enrollment Agreement (copy required by both BRS & BCBS, see #2 in send to Business Resource Services column)
  4. Documentation from prior carrier detailing all previously met deductible amounts, for both the subscriber and dependents. (Medical and prescription drug charges will be credited respectively toward medical and prescription drug deductibles only when the deductible credit request clearly separates these charges.) Not necessary for TVHP.
  5. If you have employees please provide your company's most recent Vermont State Quarterly Wage Report (C101). Make sure that the tax forms are signed and that any employees who no longer work for you are crossed off and marked terminated. If you are a new business and you have not yet filed then please supply a copy of the most recent payroll OR if you are a self-employed sole proprietor with no other employees or partnerships please include a copy of one of the following: Your most recent Schedule SE or Schedule C, Schedule K or K's if more than one partner, Schedule F, Form 1120 or W2's or W3's summary form. We do not accept Schedule E. If you are newly self employed we will need a letter of explanation indicating what day,
    month and year you started your business and what schedule you plan to file for the current year. A copy of your Trade name Registration and/or Incorporation papers as well.
  6. Evidence of coverage through spouse for any employee(s) declining coverage photocopies of valid health insurance cards (or waiver form).
  7. Once you receive your Certificate of Coverage letter from your prior carrier, please send this to our Customer Service Department with your subscriber number. Not necessary for TVHP.
  8. Check(s) for your first month’s premium made payable to Blue Cross and Blue Shield of Vermont.
  9. For divorced employees requesting dependent coverage-please provide a copy of the section of the divorce decree stating responsibility for health care coverage of dependents.

Send to:
Blue Cross Blue Shield of Vermont
Attn: Sales Department
P.O. Box 186
Montpelier, Vermont, 05601-0186