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Please enter a number from 00500 to 99999.
Number of full-time employees*
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Number of 1099 employees
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Number of Employees*

Group Insurance Questions
How many employees will be enrolled in your company’s health plan?*
Are you aware of any member on your health plan CURRENTLY receiving or PLANNING to receive care for any of the following conditions?
Please check all that apply.
- Aneurysm
- Blood disorder
- Cancer
- Circulatory disorder
- Cirrhosis
- Cystic fibrosis
- Diabetes
- Digestive disorder (only select if condition is Crohn’s, ulcerative colitis, severe IBS, enterocolitis, chronic constipation, peptic ulcer disease, colitis, GERD)
- Hepatitis
- Pregnancy
- Kidney disease (ESRD)
- Mental health
- Multiple sclerosis
- Stroke
- Substance abuse
- Transplant
- Surgery
How many employees enrolling for coverage have missed more than 10 consecutive days of work due to illness or injury in the past 12 months?*
Our insurance carriers will need to conduct an Rx history to provide you with a quote. Please click here to agree.*
Note: carriers will not be able to provide any quotes without this history.

Product Interest
What products are you interested in?
- Medical, Dental, Vision & Other Benefits (AHS)
- Medicare
- Retirement Services (401(k) / IRA)
- HR Services (Recruiting, E-Verify®, document management, HR Helpline)
- Not Sure
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Additional Information
Which of the following payroll providers do you use?*
Other provider? Please specify:
Do you have group insurance?*
Who is your current medical carrier?*
Other medical carrier:*
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Approximately how many employees are enrolled?*
What is your coverage renewal month?*

Best Time to Call
We're looking forward to speaking to you about your product interests. Please select a time range that is most convenient for us to reach out to you.
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PROVINCIAL OFFICE
800 Maplewood Avenue
Ambridge, Pennsylvania 15003

FOR ASSISTANCE CONTACT
866-861-2776
cast@decisely.com

OR
Linda Boles Mathesius
Human Resources Administrator
linda.mathesius@anglicanchurch.net

ARCHBISHOP'S OFFICE
367 Athens Highway
Building 2200
Loganville, Georgia 30052

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