You can attach a maximum of 15 files.
Call the Employer Service Center 1-800-936-6880
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.
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.
Monday to Friday from 9 a.m. to 5 p.m. CT.