Employers

1.  Please choose AssureCare location that services your group from selection below. 

2.  When the form appears, 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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