May Insurance Services, Inc.

AMERICAN COMMUNITY forms only - no new business
www.american-community.com

Administrative Guide (group) 7/05
America's Trust Request to Participate AT5RTP 4.06 
America's Preferred Employer Plan (APEP) CHOICES Benefit Chart (group) 0228 12/07
America's Preferred Employer Plan (APEP) CHOICES Brochure (group) 0239 4/08
America's Preferred Employer Plan (APEP) CHOICES Comparison Grid
Application -accepted by AC (please see under FAST TRACK below)
Application - Employee Consent to be added for acceptance of another carrier application (plese see under FAST TRACK below)
Application - Appendix for Universal Application - necessary for rates or group submission
Application Employee (sm group) 690 1/09
Application Update Employee (sm group) 690-0439 R1
Application Employee (lg group) LGEA 1/08
Application Employee Non-medical GEMNA 1/09 (American's Choice Options and Omega Solutions)
Application Employer (sm group) SGERA Rev 7/09
Application Employer (lg group) LGERA 2185-0423 12/06
Application & Addendum (individual) Trust 0549 R612/08 (for Community Flex, HSA,Triple Tier and COD)
Application - rewrite (individual) 5/09
Caremark Prescription Claim Form 12/04
Caremark Prescription Mail Order Form 9/04
Caremark Prescriptino Participating Pharmacies
Change Form (group)
Change Form (individual)
Community Flex (individual) Benefit Summary (replaces Medalist II)
Community Flex (individual) Brochure (replaces Medalist II)
Coverage on Demand Benefit Chart 259 4/08
Coverage on Demand (COD) Brochure 4/08
Coverage on Demand (COD) Request for Additional Coverage RACL 3/08
Dependent Addition Form
EFT (individual) 0365 R5
Fact Sheet 0427 R12 7/08
Fast Track - Employee Consent/Agreement Form
Fast Track - Instructions
Fast Track - list of acceptable carrier applications
Gate Keep (group 51+) 2185-0484 EMREQ 11/04
Group Enrollment Checklist 0503 R4
Health Equity (HSA "savings) Employee Application 0545 (see below under HSA)
Health Equity General Information (including fee structure, investment options, Q & A and more - see below)
HIPAA Application R1 3/06
HIPAA Brochure 2525-0163 7/97
HIPAA Rates 2185-0156 R11 7/07
HIPAA Supplement 2185-0120 9/05
HRA Health Equity Information
HRA Adminstrative Guide
HRA Features
HSA Next Generation Benefit Chart (individual) 0528 R4 10/07
HSA Next Generation Brochure (individual) 0518 R6 7/08
HSA Checklist (group) 0503 R6 4/08
HSA Health Equity Enrollment Form 0506 R6
HSA Health Equity Fee Schedule
HSA Health Equity General Information
HSA Health Equity Investment Options
HSA Next Generation Benefits Chart (group) 0536 R3 1/08
HSA Next Generation Brochure (group) 0533 R5 4/08
HSA Proposal Request Form (lg group) 4007-0088
HSA Q & A 0080 R1 8/06
HSA Rate Chart (individual) 0524 1/08
HSA Service Agreement 2185-0511 R2
Latitude (Group) Benefit Chart
Latitude (Group) Brochure
Licensing - Agent Commission Direct Deposit Authorization  0076 R5
Licensing - Agent Transfer Form
Licensing - Agent Appointment Booklet R4 11/07
Licensing - HIPPA Agreement
Licensing - Special Commission Split Agreement 649 3/06
Life Claim Form 5504-0028 R2
List Bill Employer 1605-0118 R1
List Bill Employee 1605-0117
List Bill EFT Agreement 1605 0115 R1
Medalist Benefit Chart (individual) 0447 R3 6/06 no longer sold - for reference only
Medalist Brochure (individual) 0447 R3 6/06 - no longer sold - for reference only
Medalist II Benefit Summary (individual) 0329 R4 1/08 (no longer available after 1/1; replaced by Community Flex)
Medalist II Brochure (individual) R 4/08 (no longer available after 1/1; replaced by Community Flex)
Omega Solutions Brochure (large group) AOS 0479 R3 1/07
Pre-Screen Form (individual) 2185-0394 R4
Pre-Screen Request Form (group) 4007-0422
Prescription Claim Form (see under Caremark above)
Prescription Mail Order Form (see under Caremark above)
Products (individual and group) currently marketed/available - listed by state 7/09
Prospect Form (individual) -397 11/06
Provider Flyer 0206 R1
Rewrite - see application above
Rewrite  - small group - instructions and form    
Questionnaire (indiv) - Alcohol & Drug
Questionnaire (indiv) - Allergy & Asthma
Questionnaire (indiv) - Arthritis
Questionnaire (indiv) - Aviation
Questionnaire (indiv) - Digestive & Ulcer
Questionnaire (indiv) - Drug & Alcohol
Questionnaire (indiv) - Ear & Otitis
Questionnaire (indiv) - Foreign Residence
Questionnaire (indiv) - Gastrointestinal
Questionnaire (indiv) - Hypertension
Questionnaire (indiv) - Kidney & Urinary
Questionnaire (indiv) - Migraine
Questionnaire (indiv) - Seizure & Epilepsy
Questionnaire (indiv) - Spinal
Questionnaire (indiv) - Thyroid
Questionnaire (indiv) - Tumor & Cyst
Request to Deduct Monthly Premium from Salary 1605 0117
Request to Redate Policy33144 771 1/98
Short Term Application and Rates 600A Rev 10/08
Short Term Brochure 0008 R7 6/06
Student Verification Form
Switch and Save Flyer
Switch and Save - Renewal Insert (sample)
Termination (Change) Form (group) - please use Administrative Guide on how to add, change or delete employees & dependents
Triple Tier Application and Addendum - see Application (individual) - Trust above
Triple Tier Benefit Chart (group) 0539  R3 1.08
Triple Tier Benefit Chart (individual) 0531 R4 1/08
Triple Tier Brochure (group) 0537 R5 4/08
Triple Tier Brochure (individual) 0532 R4 4/08
Triple Tier Rate Chart (individual) 0526 R4 4/08
Underwriting Guidelines (group) R13 4/08
Underwriting Guidelines (individual) 1/08