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