Life and Disability 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

HC2 Enrollment/Change Form
HC3 Enrollment/Change Form
Family Health Statement
Additional Supply Request Forms
HC2 Employee Enrollment Brochure (CT)
HC3 Employee Enrollment Brochure (CT)
HC2 Benefit Comparison by Insurance Company
HC3 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: For certificates of coverage & out of network claim forms, contact the health plan using the 800 number on the back of your medical ID card.

Aetna Dental: For dental booklets/certificates of coverage/claim forms, fax request to 860.902.7372.