Employee Health Request Form

"*" indicates required fields

Congratulations!
Your employer has partnered with Coordinated Insurance Services to ensure you find the perfect insurance solution to your unique needs. Your employer has setup a program for you to work with licensed, reliable benefit agents who have the heart of teachers.
They will seek to understand your unique situation and offer guidance towards plans that align with your needs.

Your Employer Benefit Program includes:
• Customized Health Insurance plans for you, using any Health Insurance Network offered in Utah. i.e. Select Health, Blue Cross Blue Shield, Humana, U of U Health
• Incredible savings on premiums for most employees
• Options for other Benefits like Dental, Vision, Life Insurance, Short term and Critical illness coverage, and so much more.
• Semi-annual reviews to maximize benefits

Submit this form, a Coordinated Benefit Agent will contact you and arrange a time to walk through your benefits.
Employee Name*
Address
MM slash DD slash YYYY
Do you have insurance now?
How are you paid?
This field is for validation purposes and should be left unchanged.