Request Information

Your Name:
Your Title/Job Position:
Phone #: (include area code)
E-mail Address:

Organization Name:
Address: (Line 1 of 2)
Address: (Line 2 of 2)
City:
State:
Zip Code:
Website Address:

Organization Type or Line of Business:
Number of Locations:
Number of Employees: (for organizations)
Number of Students: (for University Plans)
Please Check the Items That You Would Like More Information About:
		Self Funded Plans
		Fully Funded Plans
		Flexible Benefits/Section 125 Cafeteria Plans
		University Health Plans for Students
		Klais Health Network PPO
		Workers' Compensation MCO
		Electronic Claim Submission
		HIPAA Compliance

Additional Comments and Other Information: