Insurance - Medicare - Retirement

Small Group Enrollment

Carriers require the following enrollment documentation to determine eligibility and approval. Depending on the carrier and the size of your group, certain additional documentation may or may not required.  

Required Forms and Documents:

  1. Group Enrollment Form
  2. Employee Enrollment Forms
  3. Employer Certification Form
  4. Waiver Forms, if applicable
  5. Signed Rates
  6. Binder Check:  Company check for 1st month's premium


  1. WR-30 payroll form - (quarterly tax & wage form)
  2. Owners Tax docs:  Either K-1, Schedule C and/or 1120 form. showing 100% ownership

Send to:

1)  Forms and documents can be emailed or fax'd back to me:  732-444-5971 - (my fax)

2)  Binder check payable to the carrier:   Email copy to me.
3)  Binder check: payable to the carrier.  Mail to me.

Mail to:
Chris Kudryk, KBenefits
13 Mead Ave, Freehold, NJ  07728



Time Line:  Once all forms and documents have been collected and submitted to the carrier.  The carrier will take 5-12 business days to review and approve the policy for activation.  Once approved, ID numbers will be provided and ID cards will be mailed out and recvd within 12 business days.  ID cards can also be obtained online on your carriers' Member Portal

Examples of Owners Tax Forms: 
Provide one of the following, showing 100% ownership:

Schedule K-1
Portable network image format [166.2 KB]
Schedule C
Schedule C 1040.jpg
JPG image [568.0 KB]
1120 Form
1120 form.gif
Graphic interchange format [127.5 KB]

Member's Health Plan/Aetna also requires Owners: 

  • Personal 1040 tax form, and W-2 if there's additional income showing
  • EANJ Membership dues - Employer Association of NJ


Personal 1040 - Indiv income tax
Personal 1040 - indiv income tax form.jp[...]
JPG image [230.7 KB]

KBenefits, LLC
Christopher S. Kudryk
Call:  732-333-1976
Fax:   732-444-5971



Chris Kudryk
NPN: #7990501


KBenefits provides insurance solutions for small business owners and individuals in NJ & NY.  Contact KBenefits today and see how we can benefit you.

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