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2012 ANNUAL REPORT

Contacting EmblemHealth: Sales

If you're considering EmblemHealth insurance for your business or family,
please fill out the form below or call 1-877-411-3625.

* Required Fields

* Are you an existing subscriber with a customer service issue?
Yes No

* Are you looking for individual/family or business coverage?
Individual/Family Business

Please enter your contact information:
* Last Name:
* First Name:
* E-Mail Address:	(name@company.com)
* Company Name:
* Street Address:
* City:
* State:
* ZIP/Postal Code:
* Phone Number:	- - (000-123-4567)
Please contact me by: When should we call?

Please answer the following questions:
* Do you currently have health benefits coverage?	Yes No
If yes, what carrier do you have coverage with?
* Number of Employees / Family Members?
Renewal Date (mm/dd/yyyy)
Please tell us who referred you to EmblemHealth:
* Do you currently work through an agent/broker/general agent?	Yes No
If you have additional questions, please type in the box:

URAC - Health Care Quality Accreditation

The Leapfrog Group's Patient-Safety Improvement Efforts

Health Care Fraud-EmblemHealth Special Investigation Unit (SIU)

GHI and HIP are EmblemHealth companies. ©2013 EmblemHealth. All Rights Reserved. Last Updated 5-29-2012. Effective September 23, 2010, federal health reform may require changes to your coverage, depending on your plan. Get more information.