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Individual & Group Coverage: (800) 400-PCHP
Medicare Advantage: (877) 210-1719

Broker Materials

This page is dedicated to general forms for Broker use.  Other more specific forms and information is available on this website if you have applied for approved login access.  For information on this process please go to the main Broker Login page.

For more general needs you may download these printable forms and other materials by clicking on the following links:

2016 Group Application –  PPO Large 51>
                                              HMO Large 51>

                                              PPO Small <50  

                                              HMO Small <50

                                              PPO Small <50   for 2017
                                              HMO Small <50  for 2017

 

  • Group Product Options Quote Form -       PPO Large 51>
                                                                          PPO Small <50
                                                                          HMO Small <50

                                                                     

Group Quote Request Form           Small <50

For questions on any forms or documents you don't see here, or how to obtain a secure Broker Login code, please call 434-947-4463, ext. 281, or send an This email address is being protected from spambots. You need JavaScript enabled to view it. request.

 

 

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