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 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 *