GIC: Materials Order Form

2010 Annual Enrollment Materials Order Form

The Harvard Pilgrim Independence Plan and the Primary Choice Plan

Reminder
There's no separate Harvard Pilgrim enrollment form.

Use the GIC's Enrollment and Change Form (Form1) to enroll state employees (and their dependents) in the Harvard Pilgrim Independence Plan or the Primary Choice Plan.

Materials will be delivered during the first two weeks of April.

Order my Materials All fields must be filled in to process your order.

1. Please send me the following material:

	Qty.
1a. Harvard Pilgrim Enrollment Kits (w/Independence & Primary Choice info)	Qty.
1b. Harvard Pilgrim Independence Plan Provider Directories	Qty.
1c. Harvard Pilgrim Primary Choice Plan Provider Directories	Qty.

1d. Other Materials

2. Name of GIC Coordinator

3. Name of Agency *

4. Agency Address (include street, building/suite #) *

5. City/Town *

6. State *

7. ZIP Code *

8. Phone (to reach you if we have questions about your order) *

9. E-mail Address *

Questions about ordering materials?
E-mail: Elise_Milliken@harvardpilgrim.org

Phone: 617-509-3229.

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