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Enrollment Forms
March 2010 Renewal Letter
April 2010 Renewal Letter
May 2010 Renewal Letter
Submissions Check List
Enrollment Material Order Form (coming soon!)
2010 New Business Enrollment/Change Form (2 pages)
2010 New Business Enrollment/Change Form (page 1)
2010 New Business Enrollment/Change Form (page 2)
2010 Renewal Enrollment/Change Form
2010 Employer Agreement Form
2010 Employer Renewal Agreement Form
Broker Registration Form
Electronic Debiting Form
Atlantis Age 29 Enrollment Form
2009 Enrollment Forms
2009 New Business Enrollment/Change Form (2 pages)
2009 New Business Enrollment/Change Form (page 1)
2009 New Business Enrollment/Change Form (page 2)
2009 Renewal Enrollment/Change Form
2009 Employer Agreement Form
2009 Employer Renewal Agreement Form
Claim Forms
Emblem Claim Form
GHI Claim Form
HIP Claim Form
HRA Set Up Forms
Atlantis
Health Reimbursement Account Plan Application
HSA Set Up Forms
Emblem
Employer Set-Up Form
Health Savings Account Application
HSA Employer Contribution Worksheet
Domestic Partnership
ATLANTIS
Declaration of Domestic Partnership
GHI
Declaration of Cohabitation & Financial Interdependence
Alternative Affidavit of Domestic Partnership
HIP
Domestic Partner Coverage Rider

Enrollment and Correspondence Address:
LIA Health Alliance
Enrollment Processing Center
48 South Service Road
Suite 301
Melville NY 11747
1-800-542-5513
Fax (631) 249-6529

Bill Payments Address:
LIA Health Alliance
P.O. Box 48335
Newark, NJ 07101-4835

If you have any questions, please call 1-800-LIA-5513
 
LIA Health Alliance Website 2009