the employer connection

Supply Request


*= required field

Date:

SHIPPING INFORMATION
SHIP TO:

Company*

Contact Name*

Email*

Address* (No PO Boxes)

City, State, ZIP* ()

Telephone* (include area code)

Requestor*

SUPPLIES

Please indicate the number of each item you are requesting.

CBIA Membership Application

Employer Participation Agreement (3-50)

Employer Participation Agreement (51+)

HC Enrollment/Change Form (group products, 3-50)

HC Enrollment/Change Form (voluntary products, 3-50)

HC Enrollment/Change Form (51+)

HC Medical Plans

HC Benefit Comparison by Carrier

Group Dental Plans: 3 to 9 employees

Group Dental Plans: 10+ employees (no ortho)

Group Dental Plans: 10+ employees (with ortho)

Voluntary Dental Plans

Voluntary Vision: 12/12/12 Plan

Voluntary Vision: 12/12/24 Plan

Basic Life

Supplemental & Voluntary Life

Short-term Disability

Long-term Disability

Employer Wellness Brochure

Employee Wellness Brochure

Carrier Wellness Programs

Provider Directories: Online Instructions

Drug Formularies: Online Instructions


FOR CERTIFICATES OF COVERAGE, OUT-OF-NETWORK CLAIM FORMS, DENTAL CLAIM FORMS AND BOOKLETS, PLEASE CONTACT THE HEALTH PLAN DIRECTLY.