SUPPLY REQUEST FORM FOR 51-100 EMPLOYEES

Date: * = Required field

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)

Requester* (if not the same as above)

SUPPLIES Please indicate the number of each item you are requesting.
FORMS/MARKETING MATERIAL

Waiver Form
Group Application
51+ Enrollment Form
Dental Brochure
51+ Employee/Enrollment Brochure (CT)
Out-of-Area Employee/Enrollment Brochure
Anthem BC&BS Medicare Product Packet (limit of three)
Additional Supply Request Forms for 51+
Student Verification Form

Other:
51+ Request for Quote form
CBIA Membership Brochure and Dues Schedule

PROVIDER DIRECTORIES
ConnectiCare CT
Health Net CT
Health Net Ny or NJ
Oxford Health Plans CT
Oxford Health Plans NY

THE HARTFORD (Life & Disability)
Proof of Death
Application for Short-term Disability Income Benefits
Conversion Form
AD&D Claim Form
Application for Long-term Disability Income Benefits

HARTFORD Life Benefit Booklets (Certificates of Coverage for enrollees)
Life
Short-term Disability
Long-term Disability

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

Aetna:
• Dental booklets/Cert.-of-coverage, claim forms, fax requests to: 860-636-2350
• Dental (claim information only) 800-231-5218
ConnectiCare: 1-800-251-7722
Health Net: 1-800-441-5741
Oxford Health Plans 1-800-444-6222
Anthem Blue Cross & Blue Shield: 1-800-633-6673