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
Enrollment/Change Form
HC
HC2
51+
Family Health Statement
Additional Supply Request Forms
Employee Enrollment Brochure (CT)
Benefit Comparison by Insurance Company
Employer Participation Agreement
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
Hartford Life Benefit Booklets (Certs of Coverage) for enrollees
Life
LTD
STD
Provider Directories
CIGNA Healthcare
ConnectiCare CT/MA
Health Net CT
Health NY or NJ
Oxford Health Plans CT
Oxford Health Plans NY
List of participating Oxford USA doctors. (Search the General Physician Directory)
Medical Rates
1st Quarter (Jan. - Mar. 31)
2nd Quarter (April - June 30)
3rd Quarter (July - Sept. 30)
4th Quarter (Oct. - Dec. 31)
Dental Rates
FOR CERTIFICATES OF COVERAGE, OUT-OF-NETWORK CLAIM FORMS, DENTAL CLAIM FORMS AND BOOKLETS, PLEASE CONTACT THE HEALTH PLAN DIRECTLY.
Aetna: • Indemnity/Dental (claim information only): 1-800-231-5218 • HMO & POS (claim information only): 1-800-270-0081 • Dental booklets/Cert.-of-coverage, claim forms, fax requests to: 860-632-2084 CIGNA: 1-800-832-3211 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
Health Insurance Health Care Information Privacy Notice (updated April 2008)
