Protect Plans Forms

Checklists

Enrollment Checklist

Time to sign up? Here’s what you’ll need.

Protect Plans Enrollment Forms

Employee

Employee Application (English)

Employee Application (Spanish)

COBRA Form

Protect Plans Broker Forms

Required only with first case submitted.
The Insurgency Benefits sales agreement is available from your general agent or by email at Sales@ProtectPlans.Info.

Important Notice

Do not cancel current coverage until written approval is received from the Underwriter.

The cost of The Protect Plans quoted to a group are based on the information provided to the underwriters at the time the proposal is generated. They are subject to change. Your clients’ actual costs and eligibility are based on information provided during enrollment.

The issuance of a proposal does not guarantee a group will be accepted for coverage.

All questions on the enrollment forms must be fully and accurately answered. Otherwise rates may be modified and stop-loss coverage for members making misstatements may be rescinded. This means the plan sponsor (the employer) is responsible for these claims.

Until written approval is provided to the employer by the underwriter, do not cancel existing coverage.

Personal attention is given to each client’s set-up in the various systems (billing, eligibility, etc.). This can take longer than with fully-insured plans. 
We strongly encourage submitting enrollment forms prior to the desired effective date.