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:
Before beginning, please gather the following information:
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: * Contact Person:
Email Address: * Email Address:
Company Name: * Company Name:
Address: * Address:
City: * City:
Zip Code: * ZIP Code:
Telephone: * Telephone:
Effective Date of Plan: * Effective Date of Plan:
Agent: Agent:
Agents Phone: Agent's Phone:
Comments: Comments: