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 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.