Request Info

Request for Membership

Please complete the Request for Membership form and attach all available supplemental documents as outlined in the Request for Membership instructions section of the form.


As indicated in the Request for Membership instructions, a complete census of all eligible employees is required. The Census must include date of birth, gender, type of current coverage (employee only, employee and spouse, employee and children, employee and family, or none). If an eligible employee has no coverage through your plan, you will need to indicate if they have coverage through another group plan.

Please submit the information electronically via email if at all possible to dgraham at

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