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	Mobile Number *	Date Of Birth	SSN

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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

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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	Address1	Address2	City	State	Zipcode	Email	Employement Status	Benefit Status	Member SSN	Person Code	Plan Description	Cost Share Program(if applicable)	Tobacco Use	Hire Date	Vision	Dental	Employee Assistance	Basic Life	Additional Life	Short Term Disability	Long Term Disability	Critical Illness	Fixed Benfit	AD&D