Building Construction and Contractors

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Welcome to Building Trades Association

Building Trades Association HEALTH CARE PLAN:

Members Services Office
1181 South Rogers Circle, Suite 1
Boca Raton, FL 33487
1-800-326-7800 / Fax: 561-241-0621
**ALL INFORMATION MUST BE COMPLETED FOR A NO OBLIGATION QUOTE

Member Non-Member

SEND QUOTE VIA : FAX OR MAIL

CHOOSE YOUR OPTIONS:

DEDUCTIBLE AMOUNT:	$100	$250	$500	$1,000	$2,000
MATERNITY:	YES	NO	HMO	PPO	POS
DENTAL:	YES	NO		LIFE QUOTES

REQUESTED EFFECTIVE DATE:

NATURE OF BUSINESS:

Company Information:
Company Name:
Contact:
Email:
Address:
Address 2:
City: State: Zip:
Phone: Ext: Fax:
Number of Employees:
Number of Employees applying for coverage:
CURRENT Health Care Provider:
MONTHLY PREMIUM:
HAVE THERE BEEN ANY CLAIMS OVER $5,000 IN THE LAST 3 YEARS?	YES NO	IF YES EXPLAIN:
DOES ANYONE IN YOUR GROUP HAVE MAJOR HEALTH PROBLEMS OR IS ANYONE PREGNANT?	YES NO	IF YES EXPLAIN:

CENSUS INFORMATION: ALL INFORMATION MUST BE COMPLETED FOR A NO OBLIGATION QUOTE
	EMPLOYEE NAME	Employee Age	SEX	SMOKER?	Age OF SPOUSE	SPOUSE SMOKER?	Age and Sex of Children
Sample:	John Doe	34	M	N	32	N	5, Female
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