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 a.m. to 6 p.m.

*Indicates a required field.

Business Information:

*Effective Date:

*Number of covered employees:

*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 50 or fewer full time employees that worked on working days during the preceding calendar year. Full time employee means employees that worked 30 hours a week or more and does not include seasonal employees as defined by 26 U.S.C ยง 4980H(c)(2)(B).
  • 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: