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 faxed to the attention of Brooklyn HealthWorks at 718-643-9707.  Original documents must be mailed directly to Brooklyn HealthWorks at the following address:

Brooklyn HealthWorks
c/o Brooklyn Chamber of Commerce
25 Elm Place, Suite 200
Brooklyn, NY 11201

Enrollment forms and supporting materials must be received 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

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

>Plan Selection Form (Rider)
Choose either the “Total” or “Max” plan, sign the bottom of the form, and submit this rider 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 may not exceed 45 days from the date of hire.

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.

>Transaction 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
  • Dependent children (age 19-25) who are full-time students must submit a student affidavit every semester to maintain coverage (see form below)
  • Children of employees (age 19-30) who are not full-time students may enroll at the full individual rate under certain circumstances (call 718-843-3882 for additional information)
• Terminate employees/dependents from coverage
• Add/drop employees/dependents for COBRA coverage
• Reinstate employees to existing coverage
• Make name and address changes for employees

EMPLOYEES AND EMPLOYEE DPENDENTS MUST SIGN UP WITHIN 30 DAYS OF BECOMING ELIGIBLE FOR COVERAGE OR WAIT UNTIL A GROUP’S ANNUAL RENEWAL PERIOD.  ALL TRANSACTION FORMS NEED TO BE SUBMITTED TO BROOKLYN HEALTHWORKS—NEVER DIRECTLY TO GHI.

>NEW!! Brooklyn HealthWorks Dental and Vision Plan Options
Dental and vision plans are now available to Brooklyn HealthWorks members.  You may enroll at the time of application or wait until a group’s medical open enrollment period (annual anniversary).

>Late Paperwork Form
Submit this form with all new applications in case additional documentation is required after an application has been submitted.

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

BROOKLYN HEALTHWORKS ENROLLMENT FORMS FOR BUSINESSES WITH NEW EMPLOYEES
OR 1099 WORKERS

>Letter of Certification to Verify the Legitimacy of a New Business
For new businesses, this form must be completed by a licensed attorney or certified public accountant to verify the legitimacy of the business applying for coverage.

>CPA Model Letter to Verify Legitimacy of New 1099 Employees
A letter signed by a Certified Public Accountant on CPA letterhead needs to verify the name, salary, and full-time status of new 1099 employees.  GHI may request individual tax documents the following year to verify the legitimacy of new 1099 employees.

>Small Business Model Letter to Verify New Employees Not on NYS-45
W-4s, copies of most recent payroll stubs, and a letter signed by a duly authorized officer of the business on company letterhead must be submitted identifying new employees not on a company’s most recent NYS-45.  GHI will request an updated NYS-45 in 90 days to verify the legitimacy of new employees seeking coverage.

>Small Business Model Letter to Verify New and Existing 1099 Employees
A letter signed by a duly authorized officer of the business on company letterhead must be submitted to identify the name, salary, and full-time status of new and existing 1099 employees.  Copies of the most recent paystubs must also be submitted for new and existing 1099 employees seeking coverage.  The most recent IRS Form 1040 w/Schedule C or 1099-MISC must also be submitted for existing 1099 employees.

BROOKLYN HEALTHWORKS ENROLLMENT FORMS FOR BUSINESSES PROVIDING COVERAGE
TO STUDENTS OR DOMESTIC PARTNERS

>Full-time Student Verification
Dependent children may be covered under a family plan through age 19.  To extend coverage through age 25 for full-time students, parents need to complete this student affidavit.

TO MAINTAIN COVERAGE, A STUDENT VERIFICATION FORM NEEDS TO BE SUBMITTED FOR EVERY SEMESTER A DEPENDENT CHILD REAMINS A FULL-TIME STUDENT.

>Domestic Partner Declaration
Domestic partners seeking coverage must complete and sign this Declaration of Cohabitation and Financial Interdependence Form before a Notary Public.  Those living in a municipality or jurisdiction that allows for domestic partner registration must also submit a copy of their domestic partner registration certificate.  For information about how to register in New York City, click here.

>Domestic Partner Affidavit
Domestic partners seeking coverage who reside in a municipality or jurisdiction that does not have a domestic partner registration process must complete and sign this Affidavit before a Notary Public.

BROKER FORMS

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

>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.

>2009 Subsidized Renewal Rates 

>2010 Subsidized Renewal Rates

>2009 Unsubsidized Renewal Rates

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