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Jeffersonville, IN
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Contact
ROI Form
Company
Company Name
*
First Name
*
Last Name
*
Email address
1. Number of full time employees in your company?
How many are covered on health plan?
*
If multi state, please provide breakdown by state:
Insurance Platform
*
Fully insured?
Self-funded?
Carrier?
Total medical claims for the most recent 12 months:
*
Total RX claims for the most recent 12 months:
*
Preemployment screenings used?
*
Yes
No
