CU Name:
Address:
E-Mail Address:
City:
State:
Zip code:
County:

Telephone number:
Contact Name:
Title:
# of employees:
# of full time employees:
Does your credit union have any branches? YES NO

If YES, which county is it/are they located in (county name (s))?


Do you have coverage for retirees ? YES NO
Is your credit union under a collective bargaining agreement? YES NO

Type of information requested
BCBSM plans: YES NO
FSA: YES NO
HRA: YES NO
HSA: YES NO

Which BCBSM Plan: COMM BLUE PPO - Option 1 COMM BLUE PPO - Option 2 COMM BLUE PPO - Option 3 COMM BLUE PPO - Option 4 COMM BLUE PPO - Option 10 COMM BLUE PPO - Option 12 COMM BLUE PPO - Option 14 COMM BLUE PPO - Option 15 FLEXIBLE BLUE - Option 2 FLEXIBLE BLUE - Option 3 FLEXIBLE BLUE - Option 4 HEALTHY BLUE 70 HEALTHY BLUE 80 BLUE CARE NETWORK HMO - Pkg A BLUE CARE NETWORK HMO - Pkg E HEALTHY BLUE LIVING option 1 HEALTHY BLUE LIVING option 2 HEALTHY BLUE LIVING option 3 SELF REFERAL OPTION 1 SELF REFERAL OPTION 2

Prescription drug coverage: NONE $10 generic/brand name $10 generic/$20 brand name $15 generic/brand name $15 generic/$30 brand name 20%/$5/$25 copay

Do you want a dental coverage ? Dental Plan 2 Dental Plan 3 Blue Dental Choice - Voluntary NONE

Do you want vision coverage? BCBSM A80 Blue Vision 12/12/12 Blue Vision 24/24/24

Who is your current health care provider? AETNA BCBSM BCN CUNA MUTUAL HAP HUMANA IBC PRIORITY HEALTH PRINCIPAL TRAVELERS OTHER

If BCBSM, what is your group/suffix number?