QHP Direct Enroll

We're here to help! If you have any questions or need help completing this form, contact a BCBSVT exchange specialist at (800) 255-4550, Monday - Friday, 8:00 a.m. to 4:30 p.m.

*Indicates a required field.

Business Information:

*Effective Date: January 1, 2016

*Benefit Plan(s) Selection:

Click on any benefit plan below to view the Summary of Benefits and Coverage (SBC) or click here to compare all our qualified health plan offerings.

Covered Employees & Plan Selection:

Please list all currently covered employees and their plan selection.

*First Name of Covered Employee *Last Name of Covered Employee Employee Date of Birth *Plan Selection

Note: Employees will transfer to their current plan type (i.e. single or family).

You will need to complete and submit a Small Group Change Form for any of the changes listed below.
Follow the instructions on the form to submit the completed form.

  • Add new employee/hire
  • Change plan type (e.g. single to family)
  • Add/remove dependents
  • Cancel existing coverage

Sign and Submit

By typing my name in the "Authorized by" field below, I confirm the following:

  • This business qualifies as a small group according to Vermont state law. I have at least 1 employee, who is not myself or my spouse, and an average of 100 or fewer full time employees equivalent as calculated pursuant to IRS code ยง 4980H(c)(2).
  • I am authorized to make these benefit selections for the group.
  • All the information provided herein is complete and accurate to the best of my knowledge.
  • I will provide each employee with a copy of the Summary of Benefits and Coverage (SBC) for their selected plan.
  • I authorize the electronic submission of this form.
*Authorized by: