ABG Business Associates, LTD.
"Dedicated to the health care needs of small business"

ATLANTIS HEALTH PLAN
Group Application

Company Name: ___________________________________________
Address: ___________________________________________
Address 2: ___________________________________________
Nature of Business: ___________________________________________
Contact: ___________________________________________
Title: ___________________________________________
Total Number of Employees:  ___________________________________________
Total Number of Employees working 20 hours or more per week: ___________________________________________
Total Number of Eligible Employees: ___________________________________________
Total Number of Eligible Employees enrolling: ___________________________________________
Single: _______  2-Party: _______  Family:_______
Present Insurance Carrier ___________________________________________
Dates of Coverage:    ____/____/____ to ____/____/____  
Requested Effective Date: ____/____/____ 

Plan Applied For (Check one plan):

Plan 2 - $20 Copay Point of Service Plan: ________   

The information provided above is true and correct to the best of my knowledge. I understand that coverage and benefits may be effected by failure to provide complete and accurate information. I understand all current employees have the option of joining Atlantis Health Plan now or on my groups annual anniversary date.
_____________________________ ___________________
Signature of Owner/Partner

 

 Representative

 
____________________ _________________________
Date Representative's Phone Number

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