Small Group Submission Form

Colorado Small group
(2-50) submission checklist
Requirement for Application Submission
The following documentation is required when submitting new business:
1. A copy of the agent’s quote (based on final enrollment).
2. Small Group Employer Application (Master Application).
3. Submit an electronic enrollment application for each eligible enrolling employee/dependent(s).
4. Copy of the Colorado HeathOP excel document enrollment, listing all enrolling and waiving coverage.
5. Colorado law requires that all small employers that apply for coverage submit list of eligible employees and dependents
of eligible employees (and a list of employer determined eligible employees and dependents, if this is a different list).
6. A copy of the company’s most recent Unemployment Insurance Tax Report (UITR) reconciled with current employment
status of all employees listed. Payroll/UITR will need to be submitted for all new groups in business less than 3 months.
•Each person applying for, or waiving coverage must be accounted for on the UITR, payroll records or tax returns
(for owners). Owners / Partners not on the UITR must provide business tax documentation such as 1120 & K1s.
•If there is more than one employee in the group but only one enrolling then two quarters of the UITR are required.
Additional information may be requested at the discretion of Colorado HealthOP.
7. Copy of the prior bill. Reconcile the prior carrier bill, noting any terminations and whether they are COBRA or State
Continuation participants. COBRA or State Continuation participants are to complete a Colorado Uniform Employee
Application as they must be submitted with the rest of the group and contribute to determining the final rates.
8. A company check for the first month’s application coverage (s) made payable to Colorado HealthOP, or if ACH payment
method is selected include a voided company check.
9. Supporting business documentation for a start-up business with no UITR: Articles of Organization, W-4’s for each
employee, as much payroll as the employer has thus far.
New cases must be mailed to:
8000 E Maplewood Ave
Building 5, Ste 200
Greenwood Village, CO 80111
Please call the Small Group Broker Support at 844-417-9000 or email us at: [email protected]