Order Number Name: * Phone Number: * Email Address: * Agency Name: * What network will the group be utilizing? * PPO/EPO HMO PPO/EPO & HMO What additional documents would you like us to include? * HMO Enrollment Application PPO& EPO Enrollment Application Waiver Form Summary of Benefits of Coverage (SBC) Benefit Summary You Don't Always Need a Referral with HAP Flyer Telehealth Flyer Cost Care Estimator 2018 Small Group Delta Dental Brochure 2018 Vision Flyer Preventative Service Guidelines Where to Get Care When You Need It Genesys Choice Flyer Henry Ford Choice Flyer If you selected the SBC document, please provide the year and plan requesting: If you selected the Benefit Summary, please provide the year and plan requesting: Number of kits needed: * How would you like to receive these kits? * Agency Drop Off Novi Pick Up Mail When will you need these by? * If you selected Agency Drop Off, please provide your address: If you selected Mail, please include an address and ATTN: If you selected Novi Pick Up, our address is: 39500 High Pointe Blvd. Suite 400 Novi, MI 48375 Any special instructions? Please allow 24-48 hours to process. A service consultant in our office will reach out if additional coordination is required.