{{company_name}}
{{company_address}}
Phone: {{phone}} | Email: {{email}} | Web: {{website}}
Coverage
- Inpatient and outpatient care
- Prescription drugs
- Maternity benefits
- Mental health services
- Optical and dental (limited)
Eligibility
All permanent employees and their dependents (spouse and children up to age 21).
Claims
Submit claims via the insurer's portal within 30 days of service.
| Signature | Date | |
|---|---|---|
| {{employee_name}} | ____________________ | {{date}} |
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