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Supply Request Form
*= required field
Address 1* (Street -- NO PO
Address 2* (City, State, ZIP)
Telephone* REQUIRED (include
Requestor* (if different from
SUPPLIES Please indicate the product you want
and the number of each item you are requesting.
FORMS & MARKETING MATERIALS: Please indicate quantity
HC Enrollment/Change Form
Family Health Statement
HC Medical Plans Brochure
HC Benefit Comparison by Insurance Company
Group Dental Plans Brochure 3 to 9 employees
Group Dental Plans Brochure 10+ employees (no ortho)
Group Dental Plans Brochure 10+ employees (with ortho)
Voluntary Dental Plans Brochure*
Voluntary Dental Employee Flyer
Voluntary Vision 12/12/12 Brochure*
Voluntary Vision 12/12/24 Brochure*
Voluntary Vision Employee Flyer
Employer Participation Agreement
CBIA Membership Application
Harvard Pilgrim Health Care
Oxford Health Plans CT
Oxford Health Plans NY
FOR CERTIFICATES OF COVERAGE, OUT-OF-NETWORK CLAIM FORMS, DENTAL CLAIM FORMS
AND BOOKLETS, PLEASE CONTACT THE HEALTH PLAN DIRECTLY.
* Voluntary dental and vision materials that include quarterly rates are available online.
** CBIA and our participating carriers are transitioning to digital delivery of provider directories -- online versions provide the most current information. Please consider ordering and distributing Online Instructions for provider directories instead of printed directories.