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
Back to Forms
Order Page
|
