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Candor Workplace
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Step
1
of
9
11%
What type of plan are you interested in?
*
HMO
PPO
HSA
HRA
EPO
I'M NOT SURE/OTHER
(Select all that apply)
Are you also interested in any of these benefits?
*
DENTAL
VISION
LIFE INSURANCE
DISABILITY
I"M NOT SURE/OTHER
(Select all that apply)
Does your Business currently have a group health insurance plan?
*
Yes
No
Provide name of current provider
Provide name of current provider
*
Upload your current census, if available
Drop files here or
Select files
Max. file size: 2 MB.
If not, click NEXT
How many employees will be covered including yourself?
*
1 - 3
4 - 5
5 - 10
10+
(Select all that apply)
If more than 10, type exact number of employees:
If more than 10, type exact number of employees:
*
Business Information
Business Name:
*
Business Address:
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Contact Information
First Name:
*
Last Name:
*
Phone Number:
*
Email:
*
