Lovelace Health Plan and Lovelace Insurance Company

FIND OUT ABOUT

For Brokers

Request for Enrollment Packets

Please complete the following form to request enrollment packets or other enrollment materials. You may also request these items by contacting your Lovelace Sales Representative by phone or email.

Account Name (Required)

Account number (Required)

Choose your representative (Required)

Date Needed (MM/DD/YY)
Month: Day: Year:

(Please allow at least three working days. If you need a large number of packets or a quick turnaround, please contact your LHP representative)

Mail or Deliver To:

Name (Required)

Mail or Deliver Package:

Address Line 1 (Required)

Address Line 2 (If applicable)

City (Required)

State

Zip (Required)

Phone (Required)

Requested By:

Name (Required)		Email (Required)
Phone (Required)		Extension (If applicable)

Number of Packets (Required)

Group Effective or Renewal Date (MM/DD/YY)
Month: Day: Year:

Special Instructions (Please indicate Plan Design if this is a new account or a plan change at renewal)

* Note: "PDF" files require the Adobe® Reader® to view and print your own copies.