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
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.