May Insurance Services, Inc.

UNITED HEALTHCARE

App Adtl Dependent Form 100-5521 9/06
App ER Health Addendum 290-4395 8/06
App ER 290-4394 10/10
App ER Ancillary Prod Selection OH  2141SMO.301
App ER Benefit Options Checklist M40024 5/06
App ER Help Sheet 39200 8/05
App ER Waiver 5/30/07

App EE (existing business) 290-4396 1010
App EE (grp 10-50) 290-4397 10/10
App EE (group 2-9) 290-4398 10/10

Ohio Universal Application
App EE (group 50-99) 290-4399 10/10
App EE Help Sheet 39197 8/05
Claim Form (dental) 100-2414 3/03
Claim Form (health)
Claim Form (prescription reimbursement) 100-7297 5/06
Common Ownership
Direct Debit Form
eServices Employer Registration Form
eServices Instructions for Delegate Access
HRA Flyer 100-6682 9/05
HSA Application EE Exante 045-0130 9/04
HSA Brochure 100-6649 8/05
HSA Contribution Worksheet Exante 4/29/04
HSA Custodial/Deposit Agreement Exante 045-0131 9/04
HSA Flyer - Exante Bank 1100-6647 8/05
HSA Privacy Policy Exante 045-0132 9/04
HSA Xante Fee Schedule 045-0151 7/07
HSA/HRA Brochure 100-6481 8/05
Licensing Agreement Standard Agent 032005
Licensing Instructions
Medicare Status Change Form (employee form )
New Case Checklist (grp 2-50)
Participation Requirements
Prescription Mail Order Form 100-4213 3/06
Product Grid introduced 2007
Product Grid (all plans including HSA/dual option) 100-4611 8/05
Product Grid (HSA) 100-5614 3/05
Product Grid 290-3513 8/05
Product Grid (dental) 290-3929 7/07
Tax Documentation/Requirements (new group) 11/02
Vision - Standard Benefit OH2030 1/00

UHC Group 2-9  (forms above)
App Additional Dependents 100-5521 
App Employer Health Addendum 290-4395 App Employer 290-4394
App Employer Ancillary Product Selection OH 2141SMO.301
App Employer Benefit Options Checklist M40024
App Employer Help Sheet 39200
App Employee (group 2-9) 290-4398
App Employee Help Sheet 39197
New Case Checklist (group 2-50)

UHC Group 10-50 (forms above)
App Additional Dependent Form 100-5521
App Employer Health Addendum 290-4395
App Employer 290-4394
App Employer Ancillary Product Selection OH 2141SMO.301
App Employer Benefit Options Checklist M40024
App Empoyer Help Sheet 39200
App Employee (group 10-50) 290-4397
App Employee Help Sheet 39197
New Case Checklist (group 2-50)