1. No category

14039
HHIC Cover Sheet
for submitting Small Group Business Application
FAX NECESSARY DOCUMENTATION TO (1-888-567-5685)
Important!
One Region/Type of request must be completed for all Cover Sheets.
A Cover Sheet must be completed and inserted between the different sections of the
submission (i.e. Small Group Business Application, Enrollment Application, Supporting
Documentation).
If the submission is for a "Common Ownership", then shade the circle and the number
of companies needs to be completed in the box following "Common Ownership".
Region / Type (shade only one)
Western New
Western Change
Central New
Central Change
Application Type (shade only one)
Small Group Business Application
Enrollment Application
Supporting Documentation
Common Ownership
Number of Companies
14039