the employer connection

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 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

Wellness Flyer

CBIA Membership Application

Provider Directories

Online Instructions**

ConnectiCare CT/MA

Harvard Pilgrim Health Care

Oxford Health Plans CT

Oxford Health Plans NY

Aetna (online access only)  


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.