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If you received a mailing or are looking for medical coverage and would like a free kit on the Lifewise, HSA, Regence BlueShield and/or Asuris plans, simply complete this form and submit. We'll rush you a complete packet with plan summaries and applications. If three or more employees, please complete the online census form instead.

Please indicate what information you would like to receive:
Lifewise Health Plan  HSA  Regence BlueShield Asuris NW Health

Other Interests:
 Dental  Life  Disability  Retirement

Email Address:      (required)

Name:                

Company Name:

Address:            

City:                      State:

Zip:                       Phone:

Number of Employees (if applicable):
(Individual plans are available to any resident, employed or not)

Where did you hear about us?

To Receive a customized quote for individual medical plans, send age & data:

Person #1
Age: Smoker,     Spouse Age: Smoker,     # of Ch:

Person #2
Age: Smoker,     Spouse Age: Smoker,     # of Ch:

Comments:

Your information will not be sold, shared, or distributed in any way. The submission of
this form will only result in you receiving the requested kit!   Complete Privacy Policy


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