Association Benefits ProgramDan Roberts2020-09-20T16:06:57+00:00

Association Benefits Program

Instructions

Review the available health plans ^[pdf]
Complete the form below.

If you have questions, please contact Chad Gay at Cahaba Benefits Group at cgay@cahababenefitsgroup.com or (205) 443-8093.

Enrollment Application

Company Information
Company Name*
Company Address*
Street Address Address Line 2 City State ZIP Code
Company Phone*
Company Fax
Company Website
Federal Employer Identification Number (EIN)*
don't include dash
Company Type*
Pay Cycle*
How often are your pay periods
Office Administrator*
First Last
Office Administrator Email*
Benefit Plan
Plan(s) that you are interested in*
- Platinum Health
- Gold Health
- Silver Health
- Wellness 5000 Health
- Dental
- Vision
Please check all plan(s) you would like to offer your employees. This does not lock you in and you can change after you review the rates.
Total Number of Employees Enrolling*