Associations Information Request Form

Association:
Contact Name:
Company:
Street Address:
City, State, ZIP:	, ,
Phone Number:
Fax Number:
e-mail address:
Type of Business:
Number of Employees:
Plan Type:
Deductible Amount:
Request Effective Date:
Would you like Dental or Life Quotes?	Dental Life
Are you interested in a Prescription Drug Card?	yes no
Are you interested in maternity benefits?	yes no
Please describe current coverage benefits, Insurer name, and Rates:
Additional Comments:

For each member, please provide the following:
name, age, gender, dependent status*, number of children, and home zip code.

*dependent status can be employee only, employee and spouse, employee and children, or employee and family.

We look forward to hearing from you!

Insurance : Administrative Services : HSA Admin : Associations

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Corporate Headquarters 8716 North MoPac Expy Suite 200 Austin, Texas 78759		toll free - 1.800.822.4017 telephone - 512.533.9936 fax - 512.533.9946
Licenses: 646937, 11778