Forms & Documents

ALL REVOLUTION HEALTH PLANS - eff. 1-1-24

Patriot Plans

• Independence - eff. 1-1-24
  • Independence (2023)
• Red - eff. 1-1-24
  • Red (2023)
• White - eff. 1-1-24
  • White (2023)
• Blue - eff. 1-1-24
  • Blue (2023)
• Navy - eff. 1-1-24
  • Navy (2023)
• Admiral - eff. 1-1-24
  • Admiral (2023)
• Washington (HRA EZ) - eff. 1-1-24
  • Washington HRA EZ (2023)
• Lincoln (HRA EZ) - Retired for 2024
  • Lincoln HRA EZ (2023)

ALL PATRIOT PLANS - eff. 1-1-24

Fleet Plans

• 1500-80 - eff. 1-1-24
  • 1500-80 (2023)
• 2500-80 - eff. 1-1-24
  • 2500-80 (2023)
• 3500-80 - eff. 1-1-24
  • 3500-80 (2023)
• 5000-80 - eff. 1-1-24
  • 5000-80 (2023)
• 7600-80 - eff. 1-1-24
  • 7600-80 (2023)

ALL FLEET PLANS - eff. 1-1-24

Freedom Plans

• Glory EZ - eff. 1-1-24
  • Glory EZ (2023)
• Banner - eff. 1-1-24
  • Banner (2023)
• Stars 2000 - NEW! 1-1-24
  • Stars - Retiring for 2024 (2023)
• Stripes - eff. 1-1-24
  • Stripes (2023)
• Union - NEW! 1-1-24

ALL FREEDOM PLANS - eff. 1-1-24

Fortress Plans

• Concord II - eff. 1-1-24
  • Concord II (2023)
• MEC (no changes)

ALL FORTRESS PLANS - eff. 1-1-24

Galaxy Plans

• Diamond - eff. 1-1-24
  • Diamond (2023)
• Ruby - eff. 1-1-24
  • Ruby (2023)
• Emerald - eff. 1-1-24
  • Emerald (2023)
• HSA Qualified - eff. 1-1-24
  • HSA Qualified (2023)

ALL GALAXY PLANS - eff. 1-1-24

Self-Funded Dental

• Self-Funded Dental

• Prospect Process for Quote Requests
• Submission Requirements
• 2024-25 Renewal Calendar

• Plan Service Agreement - administered by SISCO
• Plan Service Agreement - administered by PAI (formerly TCCBA)
• Employer Certification for Self-Funding
• Preloading Template

• Enrollment & Change Form for Under 51 EEs |  Enrollment & Change Form for 51+ EEs - administered by SISCO
• Enrollment & Change Form for Under 51 EEs  |  Enrollment & Change Form for 51+ EEs - administered by PAI (formerly TCCBA)
• Medical Coverage Waiver

• BIC-ARA Underwriting and Enrollment Forms (EXCEL Spreadsheet)
• Employer Level Supplemental Questionnaire (PDF)

Visit https://www.benefitindemnity.co/araunderwriting for More Information