Employer Application

Company Information

Company Name *

Street Address *

Suite No

City *

State *

Zipcode *

EIN / Tax ID Number

Telephone Number *

Type of business

Number of Employees

Full-Time *

Part-Time

When would you like coverage to start?

Referral Information

Did anyone refer you to Redirect Health?

Yes

Employer Contribution

Please select your desired employer contribution level:

Contribution

Coverage	Contribution
Coverage	Employer	Employee
Employee	$	$
Employee and Spouse	$	$
Employee + Child(ren)	$	$
Employee + Family	$	$

	Per Week	Per 2-Weeks	Bi-Monthly	Monthly
Full-Time Employees	$	$	$	$
Part-Time Employees	$	$	$	$
Total	$	$	$	$

Don't worry, you can change this later…

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Authorized Signer or Business Owner Name

First Name *

Last Name *

Title *

Email *

Mobile Telephone *

Office Telephone

I understand that additional signature(s) will be required before my group is implemented.

This individual is also the human resource (HR) contact for the company.

This individual is also the billing contact for the company.

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Employee Details

Please add all employees.

First Name *	Last Name *	Cell Phone	Date Of Birth	SSN

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Thank You.

We have received your request and are working on your proposal!

What happens next?

A Redirect Health healthcare consultant or your Broker will contact you via email or telephone to discuss next steps. Expect a call within the next business day.

How do my employees enroll and/or add family members?

Our enrollment process is easy. During the enrollment period, we will send a text with a link to each of your employees to complete their enrollment.

I have other questions and need to speak with someone right way.

Please feel free to give us a call at 888-688-4734 or call our broker partner that you are currently working with.

Review My Information

Please confirm your information below. You can use the blue buttons on the right panel or click the back button to jump to a specific step and update your information if needed. If you forget to change something don’t worry, we can always update your information later.

Company Information

Company Name:

Address:

EIN / Tax ID Number:

Telephone Number:

Type of business:

Number of Employees

Full-Time:

Part-Time:

When would you like coverage to start?:

Referral Information

Referral Information is not selected.

I was Referred By:

They are my:

Their Telephone Number:

Employer Contribution

Your desired employer contribution level: $

Authorized Signer or Business Owner Name

First Name:

Last Name:

Title:

Email:

Mobile Telephone:

Office Telephone:

I understand that additional signature(s) will be required before my group is implemented.

This individual is also the human resource (HR) contact for the company.

This individual is also the billing contact for the company.

Human Resource Contact

First Name:

Last Name:

Title:

Email:

Mobile Telephone:

Office Telephone:

Billing Contact

First Name:

Last Name:

Title:

Email:

Mobile Telephone:

Office Telephone:

Employee Details

Back Request a Proposal

Company Information Referral Information Employer Contribution Business Owner Human Resource Contact Billing Contact Employee List Review My Information Finish

No.	First Name	Last Name	Cell Phone	Gender	Employee SSN	Birthdate	Middle Name	Address1	Address2	City	State	Zip	Email	Employement Status	Employee Class	Benefit Status	Effective Date