HC1 Supply Request Form

Supply Request Form

*= required field

Date:

SHIPPING INFORMATION
SHIP TO:

Company*
Contact Name*
E-mail*
Address 1* (Street -- NO PO Boxes)
Address 2* (City, State, ZIP)
Telephone* REQUIRED (include area code)
Requestor* (if different from above)

SUPPLIES Please indicate the product you want and the number of each item you are requesting.

FORMS/MARKETING MATERIAL: Please indicate quantity

Enrollment/Change Form
Family Health Statement
Additional Supply Request Forms
Employee Enrollment Brochure (CT)
Benefit Comparison by Insurance Company
Employer Participation Agreement
Wellness Flyer
Student Verification Form
CBIA Membership Brochure & Dues Schedule
Dental Information
Anthem BCBS Medicare Product Packet (limit of 3)
The Hartford (Life & Disability)
Proof of Death
Application for STD Income Benefits
Application for LTD Income Benefits
Provider Directories
ConnectiCare CT/MA
Oxford Health Plans CT
Oxford Health Plans NY
List of participating Oxford USA doctors. (Search the General Physician Directory)

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

Aetna:
• Indemnity/Dental (claim information only): 1-800-231-5218
• HMO & POS (claim information only): 1-800-270-0081
• Dental booklets/Cert.-of-coverage, claim forms, fax requests to: 860-632-2084
ConnectiCare: 1-800-251-7722
Oxford Health Plans 1-800-444-6222
Anthem Blue Cross & Blue Shield: 1-800-633-6673