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BENEFITS CONNECTION PROGRAM
ACA General Power Point - April 2013
Contact Us Regarding Employee Benefits
Contact Us for an Appointment
2019 Renewal form for Benefits Connection
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Third Generation since 1932,
serving personal and
business insurance in
the tri-state area.
Please advise us of your renewal decisions by completing this form and sending it to us.
Thank you for your attention to this matter. Upon receipt of your renewal elections we will begin the renewal process for your group.
Company Name *
Group's Renewal Date
Accept the MEDICAL plan(s) AS MAPPED BY THE INSURANCE COMPANY
Check here to accept renewal as offered
We want an appointment.
Contact us for a meeting
We want to change the insurance company and/or plan for MEDICAL - CONTACT ME
Contact us for MEDICAL plan changes
We will continue with our DENTAL Plan with NO CHANGES
Check here to renew DENTAL AS IS
We want to add DENTAL coverage, please CONTACT US
We want to add Dental
We will continue with our VISION plan with NO CHANGES
Check here to renew VISION AS IS
We want to add VISION please CONTACT US
We want to add Vision
Please include LEGAL SERVICES & ID THEFT as voluntary offerings at renewal for our employees.
We provide our groups with a free HR portal for assistance with benefits, plan summaries, employee costs and open enrollment elections. Also a helpful tool for HR Management.
I would like to learn more about the Employee Navigator for my group.
We are currently using the Employee Navigator.
* = Required Field
Thank you for your reply.
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