Taking care of business

Find forms that are sometimes needed for you or your employees. If your small group plan is administered by one of these distribution partners, visit their websites for forms:

CBIA Service Corp.

CBIA Health Connections:

Fully-insured plan forms |  Fixed Funding  Solutions plan forms

Access Health CT


Small group forms

Small group plan administration is being transitioned to CBIA Service Corp. for new and renewing plans beginning Aug. 1, 2020. Information is being mailed with renewals. Below are forms for fully-insured small group plans that are still being administered by ConnectiCare.

  • Small group employer handbook

    If you have questions about your ConnectiCare health plans, plan provisions, requirements and procedures. While the guide is not intended to be an all-inclusive reference, it does provide basic information on important administrative topics.

  • 2020 CT small employer group application

    If you are a small employer group (1-50 full-time employees) and you are seeking to enroll your business as a ConnectiCare group.

  • 2020 MA small employer group application

    If you are a small employer group (1-50 full-time employees) and you are seeking to enroll your business as a ConnectiCare group.

  • Small group electronic funds transfer (EFT) form

    To sign up for electronic funds transfer (EFT) of your monthly premiums to ConnectiCare

  • Small group employer order form

    If you are a small employer group (1-50 full-time employees) and you are seeking to order supplies.

  • Small group information change form

    If you are a small employer group (1-50 full-time employees) and you are seeking to make changes to the group address, contact, or to terminate a ConnectiCare group.

  • MA minimum creditable coverage - CT small group plans

    The MA Health Care Reform law requires each MA resident, eighteen years of age and older, to obtain health coverage that meets the Minimum Creditable Coverage (MCC) Standards set forth by the Commonwealth Health Insurance Connector. If the health plan does not meet the MCC Standards, Massachusetts residents may be subject to a tax penalty. Attached is a reference document that identifies plans that are creditable or not creditable.


  • Confidential large loss prognosis form

    If you are a large employer group (51+ full-time employees) and this information has been requested by a ConnectiCare representative.

  • Large group employer handbook

    If you have questions about your ConnectiCare health plans, plan provisions, requirements and procedures. While the guide is not intended to be an all-inclusive reference, it does provide basic information on important administrative topics.


  • Connecticut domiciled group

    If you are seeking to: Add a new employee.* Add a dependent.* Remove a dependent.* Terminate enrollment.* Change plans.* Elect COBRA coverage. Change a name.* Change marital status. Change an OB/GYN. Change an address.* Change a primary care physician.* Order a replacement ID Card.*

  • Massachusetts domiciled group

    If you are seeking to: Add a new employee.* Add a dependent.* Remove a dependent.* Terminate enrollment.* Change plans.* Elect COBRA coverage. Change a name.* Change marital status. Change an OB/GYN. Change an address.* Change a primary care physician.* Order a replacement ID Card.*

  • ConnectiCare customized

    If you are seeking to: Add a new employee.* Add a dependent.* Remove a dependent.* Terminate enrollment.* Change plans.* Elect COBRA coverage. Change a name.* Change marital status. Change an OB/GYN. Change an address.* Change a primary care physician.* Order a replacement ID Card.*


  • HSA/HRA plan set-up and installation form

    If you are setting up an HSA or HRA plan with the integrated Health Equity solution. This form must accompany the case submission.

  • Disabled dependent form

    If an employee would like to request continuation of ConnectiCare health care coverage for a disabled dependent who has reached the maximum dependent age limit.

  • Prescription drug reimbursement claim form

    If an employee would like to receive reimbursement for prescriptions that were purchased without the use of a ConnectiCare ID Card.

  • Prescription drug mail pharmacy order form

    If an employee would like to receive a 90-day supply of maintenance prescription drugs through the mail.

  • Out-of-plan reimbursement form

    If an employee would like to: Obtain reimbursement for a medical service that was paid for out of pocket. Request payment to be made to an out-of-plan or non-participating provider from whom a medical service was provided. Request coordination of benefits with a primary insurance company.

  • New business certification statement

    If you are a small employer group (1 – 50 full-time employees) that has been in business for at least 3 consecutive months, but has not yet filed a quarterly wage and tax statement (UC2 or UC5a), and you are seeking to enroll your business as a ConnectiCare group.

  • Employer group size certification form

    If you are an employer seeking to determine if your group meets eligibility requirements.

  • HIPAA authorization form

    If you are assisting a member with resolution of a claims or health benefit coverage issue and are seeking disclosure of the member’s protected health information as part of this process. If you are have specific claim information (claim number or date of service, provider name, and procedure/service) and want only to know if the claim has been paid or denied you can call Member Services at 1-800-251-7722. A signed authorization form from the member is not required. If you are seeking general benefit or eligibility information, you can call Member Services at 1-800-251-7722. A signed authorization form from the member is not required.

  • MA non-discriminatory certification

    For employer groups with a Massachusetts location to prove that the employer group is offering group health benefit plans on a non-discriminatory basis to all of their full-time employees who live in Massachusetts. This form must be submitted for all new groups and renewing groups at their renewal.

  • Premium credit for terminated employees form

    If you are an employer with a Connecticut insured plan and you want to elect not to pay the group health insurance premium for employees and dependents under certain conditions. These conditions are: Employee voluntarily terminates; or Employer terminates an employee for reasons other than layoff. The employee is not subject to a collective bargaining agreement requiring that you pay the premium.