EMPLOYER PARTICIPATION REQUEST
 
Employer Name
Address
City
State
Zip
Phone
Fax
Email
Contact Name
Broker Referral 
Plan That Best Describes Your Participation Interest: Enter the "letter" from the descriptions below.
A I am interested in an employer sponsored plan in which I contribute to the premiums.
B I am interested in a voluntary plan where I facilitate the education and enrollment process into the exchanges for my employees and the payroll deduction of premiums for such plans.
C I am interested in a voluntary enrollment where my employees are enrolled directly into the exchanges with assistance from HEMA on-site enrollers.
D I am interested in giving your information to my employees to call you directly about information and enrollment into the exchanges.
Number of Employees:
Current Group Health?:



If you need assistance with this form, please call 1-614-890-7373