Worksheet for Groups of 2 to 50 employees.

If you do not wish to use this online form, please send your group's census and information to:

  • Email: quotes@mclaren.org
  • Fax: (810) 733-9596
  • Mail:
    McLaren Health Plan
    G-3245 Beecher Rd
    Suite 200
    Flint, MI 48532

Before beginning, please gather the following information:

  • Employee ZIP Code
  • Employee Date of Birth
  • Spouse/Partner1 Date of Birth
  • Date(s) of Birth for Dependents (ages 0-26)
  • The requested start date for your McLaren Health Plan coverage

A McLaren Health Plan representative will contact with you within a few days of receiving the completed information.

Your proposal will include our standard health insurance plan designs with Dental and Vision options.

Please complete the following information.

Note: Fields marked with an * indicates required field

 

Contact Person:

Email Address:

Company Name:

Address:

City:

ZIP Code:

Telephone:

Effective Date of Plan:

Agent:

Agent's Phone:

Comments:

EMPLOYEE CENSUS

Employees
Count ZIP Code (Employee's Residence) Employee Date of Birth (MM/DD/YYYY) Spouse/Partner1 Date of Birth (MM/DD/YYYY) Date(s) of Birth of Covered Children, ages 0-26 (MM/DD/YYYY, comma-separated)
* *
* *
Authentication *

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1 Domestic Partner Definition

Domestic Partner means an individual who:

  • Is the same gender as the Subscriber;
  • Permanently resides with the Subscriber and has done so for at least twelve (12) continuous months prior to the individual's enrollment in McLaren Health Plan;
  • Is eighteen (18) years of age or older;
  • Is not a "dependent" of the Subscriber as defined by the Internal Revenue Service;
  • Is not married to any other party;
  • Is not related to the Subscriber by blood in a manner that would prohibit legal marriage if they were not of the same gender;
  • Is not the Subscriber's landlord, tenant or boarder; and
  • Is not an undocumented immigrant.