This is the paperwork needed to enroll in the Association Health Plan.

If you currently have group medical coverage with UHC, please reach out to your insurance broker or UHC Account Manager for assistance with the enrollment process. 

For installation of the group, please submit the following completed documentation to:,, along with your UnitedHealthcare Sales Rep.


Manufacturing Checklist with Forms


Wholesale and Retail Checklist with Forms


Please send only the original binder check to the below address for processing. Include the Tax ID
number in the memo section of the check.

UHS Premium Billing
P.O. Box 94017
Palatine, IL 60094-4017


If using overnight services:

UHS Premium Billing
Attn: Box 94017
5505 N. Cumberland Ave. Ste. 307
Chicago, IL 60656-1471


Indicate the employment or eligibility status for each employee listed on any submitted QWR or
payroll records with these abbreviations: A=Any employee submitting an application, W=Waiving,
P/T=Part-Time, T=Terminated, S=Seasonal, WP=Waiting Period.