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 (51+)

 
     
 

Dec. 2016

Jan. 2017

HC Enrollment/Change Form (3-50)

HC Medical Plans Brochure

HC Benefit Comparison by Carrier

Carrier Wellness Programs

Provider Directories: Online Instructions

Drug Formularies: Online Instructions

Temp ID Cards-Medical: Online Instructions

     

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

 
Employer Wellness Brochure

 
Employee Wellness Brochure

 


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