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Name:†
Company:†
Address 1:†
Address 2:
City:†
State:†
Postal Code:†
Phone:†
Fax:
E-mail Address:†
Total number of Employees:
Number of Employees working more than 20 hours/week:
Employees working more than 20 hours waiving coverage:
More than 49 Employees in the previous calendar year?:
Number of Employees participating:
Number of Employees employed in Minnesota:
*Percentage Employer contributes toward Employee Cost:
Current Health Care Carrier:
Renewal Date:
Major Medical 80/20 with $250 deductible:
Major Medical 80/20 with $500 deductible:
Major Medical 80/20 with $1000 deductible:
Co-payment (High Coverage Option):
MEDICA:
HealthPartners:
BlueCross BlueShield of MN:
Dental Coverage:
The Employee Name is optional, Sex and Employee Date of Birth (DOB) are mandatory, Spouse's DOB must be included if requesting coverage, Children's ages must be included if requesting coverage and should be separated by commas.
If you have more than 25 employees to enter, please give us a call.
Name:
Employee DOB:
Spouse DOB:
Dependent Children Ages:
Please comment on any employees over 65 and not on Medicare.
Comments:
