Home  |  Contact Wellmark  |  Work @ Wellmark  |      
Members  |  Employers  |  Providers  |  Brokers  |  About Wellmark

JIT KIT - Iowa Order Form

Group Demographics
Group Name:
Group Number:
Additional Description: (optional)
(Such as Plan 1, Retirees, Salaried)
Group Size:   
New Group - Effective:
Renewal  - Effective:  
Off Renewal Benefit - Effective:
Group Requesting More
 

Requestor Information 
Broker/Agency:
Requestor Name:   
Phone Number: (Include Area Code)
E-mail Address:
 

Kit Content
Health Products:   Coverage Code:   
Prescription Products:   Type:    Coverage Code:     
Dental Plan:   Coverage Code: 
Application: 
(Large group only 51+) 		Yes No  
Add Provider Directories? Yes No
 

Shipping Locations
(Please allow 7 business days to receive your order)

Broker/Agent Copy
Location Quantity:
Broker Name:   
Broker Contact :
Address:
City:
State:
Zip:
 
Location 2
Location Quantity:
Group Name:   
Group Contact:
Address:
City:
State:
Zip:
 
Location 3
Location Quantity:
Group Name:   
Group Contact:
Address:
City:
State:
Zip:
 
If you have more than three locations to send to or if you have any other information that you need to provide, please 
enter it in the "Additional Comments" field below.
Additional Comments:
Total Quantity:
Submit Form To:


Copyright© 2008 Wellmark, Inc. All Rights Reserved.
Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota. Blue Cross®, Blue Shield®, and the Cross® and Shield® symbols are registered marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.


  Terms of Use  |  Privacy  |  Security  |  Code of Conduct