Employers
1. Please choose AssureCare location that services your group from
selection below.
2. Simply click on the printer icon in your Adobe reader program to
print form.
3. Employer representative and employee must sign and date form.
4. Fax or mail a copy of completed form to the AssureCare address
listed on top of form.
5. Retain original for your files.
Plymouth, MN
Bolingbrook, IL
Hudson, OH
East
Lansing, MI
If you do not know which AssureCare location services your
group please call 1-800-328-0927.
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