INFORMATION REQUEST FORM FOR EMPLOYERS Sign up for our news letter Business Name Contact Person Phone # / ext. E-Mail Address Address 2 City State Zip NUMBER OF EMPLOYEES Full time Part time 1099 Contract Do you currently provide major medical insurance to your employees? Yes No If yes, please identify a provider below Choose United Healthcare Humana Aetna Cigna HMO Other If yes, what percentage of your employees are participating? % For those who are not insured under your current major medical program, please help us understand why (check all that apply) Not eligible Too expensive Has other coverage Contract worker Would you like more information on offering our limited medical program to your employees? Yes No Would you like more information on benefits such as: Major Medical Limited Medical Universal Life / Whole Life Term Life Critical Illness Dental Disability Income Legal Vision Other Benefit Communications AVAILABLE FORMS Please select the forms that you would like. Master Application Employee Application New Business Transmittal Claim Form Change Form Termination Form COMMENTS / QUESTIONS
INFORMATION REQUEST FORM FOR EMPLOYERS
Sign up for our news letter
Business Name Contact Person Phone # / ext. E-Mail
Address Address 2 City State Zip
NUMBER OF EMPLOYEES Full time Part time 1099 Contract
Do you currently provide major medical insurance to your employees? Yes No
If yes, please identify a provider below Choose United Healthcare Humana Aetna Cigna HMO Other
If yes, what percentage of your employees are participating? %
For those who are not insured under your current major medical program, please help us understand why (check all that apply) Not eligible Too expensive Has other coverage Contract worker
Would you like more information on offering our limited medical program to your employees? Yes No
Would you like more information on benefits such as: Major Medical Limited Medical Universal Life / Whole Life Term Life Critical Illness Dental Disability Income Legal Vision Other Benefit Communications
AVAILABLE FORMS Please select the forms that you would like. Master Application Employee Application New Business Transmittal Claim Form Change Form Termination Form
COMMENTS / QUESTIONS
