Forms & Materials
Request Materials Online

Request Materials Online

Small Employer Materials
Please complete the following information.
Contact Information
Contact First & Last Name:
Employer Group Name:
Agent/Producer Name (if applicable):
Employer Group Number:
Employer Group Renewal Date (Optional):  (mm/dd/yy)
Number of Employees/Subscribers Enrolled in SelectHealth (Optional):
Mailing Address:
City:
State:    Zip: 
Phone Number: ()  -  ext 
E-mail Address (Optional):
  Check here if any of your contact information is new.
  Check here if you are an insurance agent/producer.
Membership Guides
If you would like to request a Membership Guide, please contact your agent or broker.
You can order up to a quantity of 100 online. For larger quantities please e-mail your request to HPMarketingDistribution@imail.org or leave a message on the small employer supply request line at 801-442-5615.

Forms & Brochures Quantity Provider & Facility Directories Quantity
You can download some of these forms and brochures from our website.
Employee Application Select Value Directory
Change Form Select Med Directory
Waiver Form Select Care Directory
SelectHealth Dental Brochure SelectHealth Dental Directory
Medco By Mail Order Form
Small Employer Group Plan Options (Sales Packet for Brokers)
COBRA Form
New Hire Packet