Employer Forms

• Health Benefits Administrator and Plan Sponsor Designation
• MVP Spending Account Application

New York and Vermont Forms 

• NY Small Group Silver 4 Application
  
• NY Vision Plan Selection Form
  
• VT Vision Plan Selection Form

• Employer Large Group Size Attestation
• Employer Large Group Size Attestation (Fillable)
• Grandfathered Plan Status Certification
• Grandfathered Plan Status Certification (Fillable)
• Independent Contractor Attestation
• Independent Contractor Attestation (Fillable)
• Large Group HMO Attestation
• Large Group HMO Attestation (Fillable) 
• MVP Core Analytics

New York and Vermont Forms

• Enrollment/Change Form—New York Large Group (PDF)
• Enrollment/Change Form—New York Large Group (PDF)—Spanish
• Enrollment/Change Form Vermont Group
• New York Large Group Billing & Contact Form

• Affidavit of Group Sponsored Coverage for Common Law Employees
• Affidavit of Group Sponsored Coverage for Common Law Employees (Fillable)
• Attestation for Eligibility For Small Group Products
• Attestation for Eligibility For Small Group Products (Fillable)
• Grandfathered Plan Status Certification
• Grandfathered Plan Status Certification (Fillable)
• Independent Contractor Attestation
• Independent Contractor Attestation (Fillable)

New York Small Group

• Enrollment/Change Form—New York Small Group HMO (PDF)
• Enrollment/Change Form—New York Small Group HMO (PDF)—Spanish
• Enrollment/Change Form—New York Small Group EPO/PPO (PDF)
• Enrollment/Change Form—New York Small Group EPO/PPO (PDF)—Spanish
• New York Small Group Application HMO (Fillable)
• New York Small Group Application EPO/PPO (Fillable)

Healthy New York

• Enrollment/Change Form—Healthy New York (PDF)
• Enrollment/Change Form—Healthy New York (PDF)—Spanish
• Healthy New York Small Group Application (Fillable)
• Healthy New York Small Group Recertification Form
• Healthy New York Small Group Recertification Form (Fillable)

Vermont Small Group

• 2025 Vermont Small Group Plan Selection Form
• 2025 Vermont Small Group Plan Selection Form (Fillable)
• 2024 Vermont Small Group Plan Selection Form
• 2024 Vermont Small Group Plan Selection Form (Fillable)
• Enrollment/Change Form Vermont Group
• Vermont Small Group Application Form (Fillable)
• Vermont Small Group Recertification Form
• Vermont Small Group Recertification Form (Fillable)

• 2025 Creditable Coverage Determinations
• 2025 Creditable Coverage Template for Employers
• 2025 Non-Creditable Coverage Template for Employers

• 2024 Creditable Coverage Determinations
• 2024 Creditable Coverage Template for Employers
• 2024 Non-Creditable Coverage Template for Employers

• 2023 Creditable Coverage Determinations
  
• 2023 Creditable Coverage Template for Employers
  
• 2023 Non-Creditable Coverage Template for Employers
  
• 2023 Overview of Creditable Coverage Information

• 2022 Creditable Coverage Determinations
  
• 2022 Creditable Coverage Template Letter for Employers
  
• 2022 Non-Creditable Coverage Template Letter for Employers
  
• 2022 Overview of Creditable Coverage Information