Request for Employee Benefits    For Groups over 16 Employees
	Please complete the information requested below, and upon your submission an ALCOS Employee Benefits representative will contact you within two business days. If you wish to speak to an ALCOS representative directly, please call our Employee Benefits Division at (586) 977.6300. * Required fields   Contact Information Name * Title Company Name * Email Address * Mailing Address * City * State * Zip Code * Telephone Fax No. of Full-Time Employees Requesting information about: Health Plans Prescriptions Dental Vision Group Life, Disability Group Long Term Benefit Plans (CDHC's, FSA's, HSA's, MSA's or HRA's) Other What type of business are you involved with? How many employees do you have? under 100 100 - 500 500 - 1,000 over 1,000 I am interested in these additional ALCOS services: Edge Program Property/Casualty Workers Comp Other Risk Management Services Retirement/401(k) We appreciate any other comments you might have: