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 718-237-4274.  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@brooklynhealthworks.com or call 718-596-4550.

BROOKLYN HEALTHWORKS ENROLLMENT FORMS FOR ALL BUSINESSES

>Enrollment Check List
Complete Small Group Checkoff and submit with application, first month's premium check, NYS-45 or other tax forms, and additional documentation as needed.  Note: If you are submitting an NYS-45, make sure it is signed by an authorized officer of the business.  For all individuals on the NYS-45, please use the abbreviations noted below to indicate:

• Full-time (FT) employee (works more than 20 hours per week)
• Part-time (PT) employee
• No longer employed by the business (termed)
• Employee who has other coverage (O/C)

>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.

>Transaction Form
A transaction form must be completed for each employee seeking coverage, to terminate an employee from coverage, to enroll new groups, to add/drop new employees to existing coverage, to add/drop employee dependents from existing coverage, to reinstate employees to existing coverage, for name changes, and for address changes.  All transaction forms must be signed by employees and an authorized officer of the business.  Notes on new hire waiting periods:

• Waiting period may not exceed 45 days
• If employer wants to cover employees immediately:
• Enter “0 days” for waiting period on the new hire eligibility form, and
• Check "not applicable" on all transaction forms and write in "0 days"

>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.

>Domestic Partner Declaration
Domestic partners seeking coverage must complete and sign this Declaration of Cohabitation and Financial Interdependence Form before a Notary Public.

>Domestic Partner Affidavit
Domestic partners seeking coverage who reside in a municipality or jurisdiction that does not have a domestic partner register 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.

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