Upload Group Enrollment Documents

For Groups with Group Numbers of 5 Digits

(Groups Headquartered in Minnesota, North Dakota, South Dakota and Wisconsin)

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Please enter your information below. Attach the enrollment document(s) you would like to securely submit to Medica's enrollment department. Upon submission you will receive an e-mail confirming receipt. Only Medica’s Group Enrollment/Change/Cancellation Form and Medica Approved Enrollment Spreadsheets are accepted. *Please make sure there are no forward or backward slashes in document file names or any fields*

Note: Please retain the original document(s) and the receipt page for your records. You do not need to mail or fax these documents to us.

Submitter first name

Submitter last name

Submitter email address

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Employer group name

Type of upload

Enrollment document(s)

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Secure Document Upload