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USHL Metal Plans

Complete all fields for pricing on USHL Metal Plan portfolio. Note: Metal Plan quoting requires DOBs on all applicants.

Name:

Company:

Telephone:

Are You An Agent?:

Email:

(For quote delivery.)

Company Name:

Company Address:

Zip:

State

Plan:

Effective Date:

Your date format is invalid unless its mm/dd/yyyy

File Location:

Note: You must enter enrollee data in the order of Employee, followed by applicable Spouse, and then applicable Dependents for accurate output.

Enrollee

Last Name

First Name

Date Of Birth

Contract Type

Medical

Tobacco Use

Zip Code

Your date format is invalid unless its mm/dd/yyyy