BlueCross® BlueShield®
BluePlus®
of Minnesota
Independent licensees of the Blue Cross and Blue Shield Association
MII Life
An independent licensee of the Blue Cross
and Blue Shield Association
DELTA DENTAL®
Delta Dental Plan of Minnesota
Small Employer Reform Application
(2-50)
  A. EMPLOYER INFORMATION - Please print all information in black or blue ink.
1. Company Name
2. Contact Person (Group Leader)
3. Address
Street
City
State
Zip Code
County
 
4. Billing Address Street City
State
Zip Code
(if different than above)
5. Telephone Number
6. Fax Number
 7. Company Web Site 8. Company Email Address
() ()
9. Type of Ownership
10. Nature of Business
11. Years in Business
Proprietorship Partnership Corporation
12. Federal Tax ID #
Are all employees paid wages under this Federal Tax ID #?
Yes No
   If No, explain
13a. Current Group Carrier (Include current bill copy. State “none” if no current group coverage.)
13b. If you have current group coverage, what is the current coverage waiting period for new employees?
 
  B. PARTICIPATION/ELIGIBILITY INFORMATION
Yes No 1. a.
Is the headquarters of your business located in Minnesota?
If No, provide address of headquarters:
 
Yes No   b.
Are you a member of a controlled group?
  If Yes, please provide the company name, address and number of
employees, owners and partners, for all members of the controlled group:
Yes No   c.
Did you employ an average of 2-50 persons, including owners and partners, who worked at least
20 hours per week during the preceding calendar year?
  d.
Current number of employees, including owners and partners, working 20 or more hours per week.
  e.
How many employees work outside the State of Minnesota?
Yes No   f.
Do you have any leased, temporary, seasonal, or independent contract employees who are applying
for this group coverage?
If Yes, provide names:
  2. a.
Who is eligible for coverage? (example: all employees, management, nonunion...)
  b.
How many hours a week does an employee have to work to be considered eligible for coverage?
    c.
Coverage waiting period (select one):
 NONE 30 days 60 days 90 days
Benefits will begin on (select one):
 Date of hire (only available with NONE)
  First day after completion of waiting period (Not
  available with NONE)
  First day of the month after completion of waiting period
 
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3. a.
What is the total number of employees eligible for coverage based on your requirements?
  b.
How many eligible employees are applying?
  c.
How many eligible employees are waiving due to other group coverage, MCHA, Medicare,
Medical Assistance or General Assistance Medical Care?
  d.
How many employees will be in a coverage waiting period on the group's requested effective date?
(Submit applications for all employees in a waiting period. Their coverage will be effective
upon completion of their waiting period.)
Yes No 4.
Is your business currently providing group coverage for any eligible employees or dependents due to a leave of
absence, disability, or continuation/COBRA extension?
If Yes, provide names:
  5.
Employer Contribution (the employer must contribute at least 50% of the employee's premium)
 
   
Health   
  
Life/AD&D   
  
Dental   
  
Disability   
Employee:
   %   %   %   %
Dependent:
   %   %   %  
Yes No 6.
Do you want to provide domestic partner coverage?
  If Yes: same gender same and opposite gender
/ / 7.
Requested effective date. Please allow one (1) month for processing. No existing coverage should be
cancelled until written notice of approval of this application is received by the employer.
 
  C. BENEFIT SELECTION
I. Medical Coverage
Is the group applying for a dual choice health benefit plan? Yes No
  • If Yes, only select one base plan. We will include rates in the offer for the available matching plans.
  • If No, you can request to receive rates in the offer for six health plans.
 
A. Aware Gold®
B. Aware Gold with Copay
C. Comprehensive Major Medical with Copay
$20 copay
$25 copay
D. Comprehensive Major Medical with Deductible
$300
$500
$1,000
$2,000
E. Preferred GoldSM
F. Preferred Gold Limited with Copay 90/10
G. Preferred Gold Limited with Copay 80/20
H. Preferred Gold Limited with Deductible
$300
$500