APPLICATION FORMS

APPLICATION FORMS

For assistance please call1-855-CORSANA (267-7262)

What forms do I need to fill out?

To apply for Corsana Group Benefits EVERY applicant must complete Form 1. For any other forms which may be required, or are optional, in order to complete your application please see the table below. Please feel free to contact us if you have any questions.

INSTRUCTIONS

  • Please be sure to complete ALL necessary forms before sending your application in. We do not accept emailed or faxed applications - mail only please.
  • Please be sure to send the required payment with your application. Click the "How do I make payment?" link below for further details.
  • Ensure you sign and date all forms where required so that we might process your application as quickly as possible.
  • You may open the forms online below, print them, complete them and sign and date them OR you may find the forms at the back of our enrollment package.

Any applicant required to show evidence that they are applying within 60 days of hire, retirement, full-time transfer etc. must complete this form.

FORM 1

Corsana Group Enrollment Form

ALL applicants must complete this form.

FORM 2

Statement of Health Form

Any applicant wishing to be considered for the Optimum level of coverage must complete this form.

FORM C1 Change Form

Change in Coverage Details

Any current plan member wishing to make amendments to his or her coverage may use this form to do so.

OUR PARTNERS

partner1.jpg
partner2.jpg
partner3.jpg
partner4.jpg
partner5.jpg
partner6.jpg
partner7.jpg