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Are you an employer or broker? Please provide us with the following information and we will contact you with plan information.
Company
Address
City
State
Zip
Telephone
 

Plan Information
Number of Employees?
Number of eligible employees?
Number of employee locations?
States where eligible employees reside (List All)
What is the current health insurance plan?
Number of employees on current plan?
Does the employer make a contribution? Yes | No
If Yes, percentage or $ amount?
Why is the company looking for a new solution?
Comments or Questions
 
You may download the form (PDF, 184 KB), complete it, and fax it to CHC at (972) 929-2973.