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To "Request for Individual Health Plan Information - Please complete this form and Myers-Stevens will mail or email you the requested information."

Coverage Desired:    Health        Disability        Dental        Life

 First Name
 Last Name
E-mail
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
Home Phone
Daytime Fax
Home Fax
Birth Date / /    
Spouse's Birth Date / /    
Children's Birth Dates / /    

/ /    

/ /    

/ /    

/ /    

Do you currently have health coverage?           Yes         No
Current Insurance Company
Type of Insurance          Group      Individual      COBRA
Current Monthly Premium

Do you have any special concerns about changing your health plan?

Health Insurance Coverage Desired:

        PPO           HMO            POS        

For explanation of these plans

 

Desired Start Date of Coverage:      Within a month    Within three months

                          Within a year

       Other

Questions or comments?  Please tell us:

 Please mail    email     the information.

 

A representative may call you to ask questions about this information. 

Please call us with your questions. 

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