Business Insurance Coverage Form

Group name:

 

SIC Code or Nature of Business:

 

Address 1:

 

Address 2:

City:

 

State:

-- AK AL AR AZ CA CO CT DC DE FL GA HI IA id IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY  

Zip:

 

County:

 

Phone:

  (xxx-xxx-xxxx)

Fax:

(xxx-xxx-xxxx)

Email:

Current Carrier:

Plan Design name:

Monthly Premium:

$

Effective or Renewal Date:

  (mm/dd/yyyy)

Contact Person:

 

How did you hear about Devon Health? (Example: advertisement, web search, article, etc...)

 

To the best of your knowledge, are any employees or dependents not in good health, currently disabled, currently pregnant, or recovering from a recent major illness? 

Yes

No

If yes, please provide details:

 

Total Number of Full-Time Employees:

 

Total Number of Part-Time Employees:

 

Total Number of Insurance Waivers:

 

Are any retirees covered? 

Yes

No

Is anyone currently on COBRA? 

Yes

No

Is your plan contributory? 

Yes

No

If yes:

Medical

Dental

Vision

Coverage requested: 

Optional Rx

Preferred EAP

Maternity

STD*

LTD*

*Employee salary required (Devon Health account executive will contact you for salary information)