McLaren Health Plan will contact you within a few days of receiving your completed worksheet.

Note: Please complete the following information - * indicates required field

Contact Person: *

Email Address: *

Address: *

City: *

Zip Code: *

County: *

Telephone: *

Effective Date of Plan: *

Agent:

Agent Phone:

Comments:

Subscriber Date of Birth: *

Subscriber Tobacco Use (Y/N): *

Spouse/Partner Date of Birth: *

Spouse/Partner Tobacco Use (Y/N): *

Date of Birth (1st Child):

Date of Birth (2nd Child):

Date of Birth (3rd Child):

Date of Birth (4th Child):

Date of Birth (5th Child):

Date of Birth (6th Child):

Date of Birth (7th Child):

Date of Birth (8th Child):

Date of Birth (9th Child):

Date of Birth (10th Child):