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Supply Request

 

Please use this form to request bulk supplies for NEW and RENEWING business.

 

For all other forms and documents, visit the Fixed Funding Solutions and ACA-Compliant sections of our website.


*= required

Date:


Company*

Contact Name*

Email*

Address* (No PO Boxes)

City*

State*

Zip*

Telephone* (include area code)

Requestor*


Please indicate the number of each item you are requesting.

We will mail your request within two business days of our receipt of this form. If you require immediate assistance or faster turnaround, please contact your CBIA Account Manager.

Administration  

CBIA Membership Application

Employer Participation Agreement
(Fixed Funding Solutions)

Fixed Funding Solutions Enrollment/Change Form

Fixed Funding Solutions Stop Loss Application

Employer Participation Agreement
(ACA-Compliant Plans)

ACA-Compliant Plans Enrollment/Change Form

Employer Participation Agreement
(51+ employees; non-medical)

Waiver of Coverage Form

Medical  

Fixed Funding Solutions
Small Group Medical Plans Brochure

specify year (2022/2021) and quantity

Fixed Funding Solutions
Large Group Medical Plans Brochure

specify year (2022/2021) and quantity

ACA-Compliant Plans
Medical Plans Brochure

specify year (2022/2021) and quantity

Dental  

Dental Plans Brochure: 2 to 50 employees

Dental Plans Brochure: 51+ employees

Vision  

Voluntary Vision 12/12/12 Plan

Voluntary Vision 12/12/24 Plan

Life and Disability  

Basic Life

Supplemental & Voluntary Life

Short-term Disability

Long-term Disability

Voluntary Accident & Illness Benefits  

Employer Brochure

Employee Brochure

Other Products  

Cyber Insurance Employer Brochure

Identity Theft Employer Brochure

Identity Theft Employee Brochure, Voluntary

Identity Theft Employer Brochure, Group Gold

Identity Theft Employer Brochure, Group Platinum

Online Instructions  

Fixed Funding Solutions Provider Directories

ACA-Compliant Plans Provider Directories

Fixed Funding Solutions Drug Formularies

ACA-Compliant Plans Drug Formularies

Temp ID Cards

 


For Certificates of Coverage, out-of-network claim forms, dental claim forms, and booklets, please contact ConnectiCare directly.