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Step 1: Company Information
Note: Washington State requires a minimum of 2 eligible employees to receive coverage.
Company Information
* Denotes required field
Company Name *
Zip *
Type of Business *
UBI Number
Group Contact Name *
Phone *
Contact Title *
Fax
Company Address *
E-Mail *
City *
Requested Effective Date
(MM/DD/YYYY) *
State *
Comments
Current Medical Plan Information
Renewal Date
(MM/DD/YYYY)
Current Carrier
Individual Deductible
Current Dental Plan Information
Renewal Date
(MM/DD/YYYY)
Current Carrier
Individual Deductible
Current Rates
Medical
Dental
Employee
Employee & Spouse
Employee & Child(ren)
Employee & Family
