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Helpful Documents

The documents listed below are available for download. Please click on each title to download a PDF copy.

Individual Market

  • RSDA/Wellmark Supply Order
  • 5Star Life Insurance Company Term (All forms in 5Star Folder)

Group Market

  • Group Quote Request Form
  • Iowa Uniform Health Application N5401 (UHC & Wellmark Combined)
  • Wellmark Rights and Responsibilities
  • Wellmark New Account Quote Request (2-100) M53280
  • Wellmark Health Only Application (N5408)
  • Wellmark Health, Dental, Life Application (N5411)
  • Wellmark Membership Change Form
  • Wellmark PCP Form
  • Wellmark MSP Form
  • Wellmark Large Group Account Certification Form N53161
  • UHC Employee Enrollment Form 2-99 SB.EE.07.IA
  • UHC Employee Enrollment Form 51-99 SB.EE ONEQ.07 IA
  • UHC Employee Enrollment Form 100+ LG.EE.07.IA
  • UHC Employer Enrollment Application for Iowa 2-99 250.27.15
  • UHC Employer Enrollment Application for Iowa 100+
  • UHC Employer Enrollment Addendum 51-99
  • UHC Iowa Uniform Group Health Application with Rights and Responsibilities
  • Delta Dental Enrollment/Change Application
  • Dearborn National Enrollment Form

Agent Support

  • Agent Record Form
  • ACH Authorization Form for RSDA
  • RSDA Commission Statement PDF Authorization
  • W-9 Form
  • Wellmark Agent of Record Form AOR-1
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RS Doughty

R. S. Doughty Associates, Limited.
3345 106th Circle, Urbandale, IA 50322
©2012 R. S. Doughty Associates, Limited.

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