FORMS

SLHP Request for Proposal (RFP) Form - This electronic form is used to tell us all about the existing group employee benefits program and what the plan sponsors want going forward. Please click on the form name and download it (select file then "save as" in your browser) and complete this electronic form and return it to stace@slhealthplans.com

SLHP New Business Transmittal Form - This electronic form is used to document Broker, GA and Agency information for each new case placed with SLHP. Please click on the form name and download it (select file then "save as" in your browser) and complete this electronic form and return it to stace@slhealthplans.com

SLHP HIPAA Business Associate Agreement (BAA) - This form is to be executed between any two parties that intend to share Protected Health Information (PHI) pursuant to the Health Insurance Portability and Accountability Act of 1996. Please click on the form name and download it (select file then "save as" in your browser) and complete this electronic form and return it to stace@slhealthplans.com Contact Stace Bondar for Vendor Business Associate Agreements 443-415-6590 stace@slhealthplans.com

SLHP Employer Application - This electronic form is used to apply to The Loomis Company for complete health plan administration services through SL Healthplans. Please click on the form name and download it (select file then "save as" in your browser) and complete this electronic form and return it to stace@slhealthplans.com

SLHP MEC Only Enrollment Form - This electronic form is used for MEC plan enrollment only. It does not contain health questions as MEC's are not medically underwritten. Please click on the form name and download it (select file then "save as" in your browser) and complete this electronic form and return it to stace@slhealthplans.com

SLHP Individual Health Questionnaire - This electronic form is used for medical underwriting purposes. Please click on the form name and download it. (select file then "save as" in your browser). Please have the participant complete the questionnaire on behalf of him\herself and their dependents if applicable. Return it to stace@slhealthplans in a HIPAA compliant manner as once it is completed it will contain Protected Health Information (PHI). PHI may be transmitted if it is password protected. Winzip, Dropbox and EasyApps are acceptable ways to transmit this form.

SLHP Enrollment Change Term Form - This this electronic form is used to make changes in a participants enrollment status or to terminate enrollment in a plan. Please click on the form name and download it (select file then "save as" in your browser) and complete this electronic form and return it to stace@slhealthplans.com

​If you have any questions please feel free to contact Tony 860-391-3450, tony@slhealthplans.com or Stace 443-415-6590, stace@slhealthplans.com

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