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Town Of Allenstown

smulholland@allenstownnh.gov

16 School St, Allenstown , NH, 03275, US

603-485-4276

MEDICAL INSURANCE QUESTIONNAIRE FOR 2017

This form must be completed to provide the Town with the necessary information to set up the new HMO Site of Service medical insurance plan for Town employees.  The new plan will involve an HRA or Health Reimbursement Account which will be managed by a third party vendor.  If you have any questions in regards to this form please do not hesitate to contact the Town Administrator.  

Please complete a box below for yourself and each dependent to be covered by medical insurance. The following information will be needed.

First Name, Middle Initial, Last name, DOB, Gender, Relationship to the Employee and Social Security Number

Draw Type
I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.