Brooklyn HealthWorks Applications and Forms

This section has links to and instructions for the Brooklyn HealthWorks enrollment application and other forms, which may be downloaded by clicking the form names below.  To expedite the application process, enrollment forms and supporting documentation may be e-mailed to Theresa Reyes at treyes@brooklynchamber.com or faxed to the attention of Brooklyn HealthWorks at 718-643-9707.

The first month's premium check made out to "Brooklyn HealthWorks" must be mailed directly to the following address:

Brooklyn HealthWorks
c/o Brooklyn Chamber of Commerce
335 Adams Street, Suite 2700
Brooklyn, NY 11201

To expedite the approval process, please submit enrollment forms and supporting materials by 5 p.m. on the 15th of the month for coverage to be effective on the 1st of the following month.  If you have questions about the enrollment process and forms below, please contact Theresa Reyes via email at treyes@brooklynchamber.com or call 718-943-3884.


Brooklyn HealthWorks Enrollment Forms For All Businesses (PDF links)

>Group Medical Plan Application
Complete Sections A-E and have a duly authorized officer of the business complete and sign Section F.

>Group Medical Plan Selection Form
Choose the "Total" high deductible plan with or without drugs, sign the bottom of the form, and submit this form with the application.

>New Hire Eligibility Policy
Complete this form to establish the length of time new employees must wait before they are eligible for health insurance coverage.  Please note that the waiting period for new hires may not exceed 45 days from the date of hire, and this waiting period does NOT apply to owners/employees enrolling at the time of initial application.

NEW EMPLOYEES MUST ENROLL WITHIN 30 DAYS OF BECOMING ELIGIBLE FOR COVERAGE (AFTER WAITING PERIOD HAS ELAPSED) OR WAIT UNTIL A GROUP’S ANNUAL RENEWAL PERIOD.

>Employee Medical Enrollment/Change Form
A transaction form must be completed for each employee seeking coverage.  Employees who do not sign up for coverage at the time of initial application must wait until a group’s annual renewal period to enroll unless a qualifying event has occurred, such as loss of coverage from another source (e.g., spousal coverage or public health insurance).  All transaction forms must be signed by applicable employees and an authorized officer of the business.  Use this form also to:

  • Add newly hired employees
  • Add employee dependents, including spouses, domestic partners (see additional forms below), and children
  • Terminate employees/dependents from coverage
  • Add/drop employees/dependents for COBRA coverage
  • Reinstate employees to existing coverage
  • Make name and address changes for employees

NEW EMPLOYEES AND EMPLOYEE DEPENDENTS MUST SIGN UP WITHIN 30 DAYS OF BECOMING ELIGIBLE FOR COVERAGE (E.G., WHEN NEWLY HIRED, AFTER LOSING OTHER COVERAGE, AND AFTER A MARRIAGE OR BIRTH) OR WAIT UNTIL A GROUP’S ANNUAL RENEWAL PERIOD. 

ALL COVERAGE CHANGES NEED TO BE SUBMITTED TO BROOKLYN HEALTHWORKS—NEVER DIRECTLY TO GHI.

    >Group Dental/Vision Plan Application
    Submit this form when first applying for the dental/vision plan options.

    >Employee Dental/Vision Enrollment and Change Form
    Use this form to add employees and dependents to one of our dental/vision plans or to make coverage changes after initial enrollment.  Employees and dependents enrolling only in dental/vision plans must complete this form.

    ALL COVERAGE CHANGES NEED TO BE SUBMITTED TO BROOKLYN HEALTHWORKS—NEVER DIRECTLY TO GUARDIAN OR DAVIS.

    >Group Life/AD&D/Long-term Disability Plan Application
    Submit this form when initially enrolling in our life/ AD&D/ long-term disability plans.  Each enrolling employee must designate beneficiaries using the employee form below.

    >Employee Life/AD&D/Long-term Disability Enrollment Form
    Employees enrolling in our life/ AD&D/ long-term disability plans must complete this form and designate primary and contingent beneficiaries.

    >Group State Statutory Short-term Disability Plan Application
    Use this form to enroll all employees on payroll in this state-mandated short-term disability policy.  Submit this application to the Brooklyn Chamber of Commerce – not directly to Guardian. 

     


     

    Documentation Requirements And Misc. Forms

    >Documentation Requirements
    This sheet summarizes the payroll and tax documentation requirements for enrolling in Brooklyn HealthWorks.

    >Letter of Certification
    Use this form to document income for new business owners/partners and employees.  GHI may also request this form be completed to verify the start of a business, income and hours worked for new employees, tax filings, etc.  A certified public accountant (CPA) or a lawyer must complete this form.  If you need to find a CPA or lawyer, click on the "Membership Directory" link at the top of this page.

    >Broker Compensation Disclosure Brokers are required to disclose the compensation they receive on the sale of insurance products in New York State.  Please contact your broker about Brooklyn HealthWorks compensation levels or call Theresa Reyes at 718-943-3884 to discuss current commissions.


    Brooklyn HealthWorks Enrollment Forms For Domestic Partners

    You may enroll a same-sex or opposite-sex domestic partner of a covered employee during a group's annual renewal period or within 30 days of a partner losing coverage from another source.

    >Domestic Partner Declaration
    Domestic partners seeking coverage must complete and sign this Declaration of Cohabitation and Financial Interdependence Form before a Notary Public.  Submit evidence of cohabitation and financial interdependence with this completed form. 

    >Domestic Partner Affidavit
    Domestic partners seeking coverage must complete and sign this Affidavit before a Notary Public.


    >Tips and Reminders on Effectively Managing Brooklyn HealthWorks Plans


    Broker Forms

    >Broker Sheet
    Complete this form and submit with each new group application to identify the broker of record.

    >Broker Commission Direct Deposit Authorization

    >Selling Agent Agreement
    Brokers selling Brooklyn HealthWorks must have a selling agreement on file with GHI.

    >Selling Agent Appointment
    Brokers selling Brooklyn HealthWorks must have a selling agent appointment on file with GHI.

    >NYS Disability Selling Agent Licensing Agreement


    Previous Year Plan Rates And Summary Of Benefits/Co-payment Schedule

    >Summary of Benefits and Co-payment Schedule for Standard Medical Plans (those without a high deductible)

    Subsidized Rates (Grandfathered Plans)

    >2010 (Jan-Sep) Subsidized Renewal Rates

    >2010 (Oct-Dec) Subsidized Renewal Rates

    >2011 Subsidized Renewal Rates

    >2012 Subsidized Renewal Rates

    Subsidized Rates (Non-Grandfathered Plans)

    >2010 (Oct-Dec) Subsidized Renewal Rates

    >2011 Subsidized Renewal Rates

    >2012 Subsidized Renewal Rates

    Unsubsidized Rates (Grandfathered Plans)

    >2010 (Jan-Sep) Unsubsidized Renewal Rates

    >2010 (Oct-Dec) Unsubsidized Renewal Rates

    >2011 Unsubsidized Renewal Rates

    >2012 Unsubsidized Renewal Rates

    Unsubsidized Rates (Non-Grandfathered Plans)

    >2010 (Oct-Dec) Unsubsidized Renewal Rates

    >2011 Unsubsidized Renewal Rates

    >2012 Unsubsidized Renewal Rates