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.

Employer Name*

Employee Name*

First Last

Phone*

Email*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date Of Birth*

Do you have insurance now?

Yes

Who is your current insurance provider?

How are you paid?

Hourly

Salary

What is your annual income on your taxes? (If you don't know now we'll cover this later)

Comments

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