Group Health Insurance Information Request Form
Contact Information (
*
required fields)
*
First name:
*
Last name:
*
Title:
*
Company name:
*
Address:
Address 2:
*
City:
*
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
ZIP Code:
County:
Bucks
Chester
Delaware
Montgomery
Philadelphia
Other
*
Phone number:
*
Email address:
Group/Insurance Information
Is your group currently insured by Independence Blue Cross?
Yes
No
If yes, what is your IBC Group Number?
If no, what is the name of your current carrier?
Is the above address your corporate headquarters?
Yes
No
Indicate the number of employees eligible for insurance.
1-99
100-499
500 or more
When does your current policy renew?
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Type of information you are requesting:
Health insurance
Prescription drug coverage
Vision coverage
Dental coverage
Disability insurance
Life insurance
Accident, Critical Illness, and Cancer Insurance
Personal Life Management
COBRA
Travel
Workers compensation
Do you currently work with:
Association
Broker
Consultant
Other
If you do, what is the name of the person/entity?
