Care Access Health Plan

Broker Agent Information

*Broker/Agent Name:

*Agency Name:

*Address:

*City:

*Zip Code:

*Telephone Number:

Fax Number:

*E-Mail:

Employer/Group Information

Name of Business:

Business Address:

City:

Zip:

Telephone Number:

Nature of Business:

SIC Code:

If more than one location/division, please complete
census for home office and each working location

Does Group have current coverage:

In Yes, Current Carrier:

How Long?

Current Plan Design:

Please fax census information including EE birth dates, gender, number of dependents/materials to 305-614-5011

Proposal Plan Options

Pick Appropriate Category

Medical:

Dental Rider:

Hospital Supplement Rider:

Requested Effective Date:

Total # of Active Full-Time Employees:

Part-time:

Is the quote excluding any of the following:

Management	Non-Management
Salary	Hourly
Union	Non Union
Other

Comments:

NOTE: Additional Information/documentation will be required
to establish eligibility and participation requirements.

Group should not cancel their present group coverage without receiving approval from
Care Access Health plan. It is the Group's responsibility to ensure there is no lapse in coverage.

© 2006 Care Access Health Plan, Inc. • Licensed by the Florida Office of Insurance Regulation • Privacy Policy • info@mycareaccess.com
P.O. Box 4276 • Hallandale, Florida 33008-4276 | Phone: (305) 614-5010 • Toll Free: 877-411-CAHP (2247) • Fax: (305) 614-5011