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.

If you are requesting a quantity of material for multiple years (ie. 2017 and 2018 medical plan brochures), please indicate that also.

Supplies are mailed within two business days of our receipt of this form. If you require immediate assistance or faster turnaround, please contact your CBIA Account Manager.

CBIA Membership Application

Employer Participation Agreement (3-50)

Employer Participation Agreement (51+)

   

HC Enrollment/Change Form (3-50)

HC Medical Plans Brochure

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

   

Voluntary Accident & Illness Benefits: Employer Brochure

Voluntary Accident & Illness Benefits: Employee Brochure

   
Employer Wellness Program Brochure

Employee Wellness Program Brochure

Carrier Wellness Programs

   

Immediate Care Choices

Provider Directories: Online Instructions

Drug Formularies: Online Instructions

Temp ID Cards: Online Instructions


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