CHCC Employer Opt-In Form
This form must be completed and signed before we can accept ChoiceCare or SelectCare enrollments from your employees. You can sign electronically below and press "submit" or print and fax to 866-402-4243 or print and mail to Apogee Members LLC, CHCC Health, P.O. Box 585, Rosemont, IL 60018 This form is not an application for insurance. Do not cancel any existing insurance programs until approved in writing. This form does not bind the signer to any financial liability for any products enrolled in by themselves or their employees unless informed of and agreed to in a separate application for coverage. (To sign use your mouse, or finger on touch screen device.)
Business Name
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Brief Description of Business (i.e. Restaurant, Florist, Construction etc.)
CHCC affiliate your business is a member of (if not known no worries!, just fill in zip code and we will look up for you)
*
Approximate number of full time employees
Full Time
Approximate number of part time employees
Part Time (32 hours a week or less)
Contact Person Name
*
First Name
Last Name
Contact Person Title
*
Contact Person E-Mail
*
example@example.com
Contact Person Phone Number
-
Area Code
Phone Number
Number
Employer Contribution (this does not obligate you)
Employer will not contribute
Employer will contribute (creates no obligation, we will contact you to discuss)
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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