New ICHRA Enrollment Forms Are Now Available for Download

Sept. 13, 2022

We recently revised the individual coverage health reimbursement arrangement (ICHRA) enrollment forms. Updated versions are now available on the agent Forms and Documents page.

ICHRA documents include:

  • New Group Checklist
  • Administrative Services Agreement (ASA)
  • Employee Enrollment Form
  • Enrollment Census 
  • Electronic Funds Transfer (EFT) Form
  • Payroll Express Form

The Administrative Services Terms and Conditions and Plan of Benefits are also available. You must include these two documents when sending the ASA to a group. 

We will no longer require the ICHRA Election Form when sending in a census. We will send a member fulfillment email to new groups to distribute to enrolled employees. This email will detail their obligations for remaining on the ICHRA account.

Please send all completed forms to

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