January 17, 2021

2021-Renewal Form for Benefit Connection

General Information
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 *
Your Name
Phone
Email *
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
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
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. Yes
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.
Your Comments
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