Health Plan Election Effective 10/1/2016 Firm Name* Group #* As shown on the renewal letter sent via USPS Dept #* As shown on the renewal letter sent via USPS Do you wish to change plans?* YES NO If YES above, please select which plan you wish to change for the 2016-2017 plan year PLAN 1 PLAN 2 PLAN 3 PLAN 4 PLAN 5 PLAN 10 PLAN 15 PLAN 20 Name and Email of the Primary Health Plan Firm Contact First Name Last Name Email Address What is 2+2?* Prove you are a human
