the new connecticut partnership plan Enroll Online

Partnership Plan 2.0

Once you have completed the form below, a Partnership Plan representative will contact you for more information. After an application has been accepted, groups will be required to sign a participation agreement before enrollment begins.

* Required

Group Name *

Proposed Start Date *

Requestor's Name*

Requestor's Title*

Requestor's Email*

Requestor's Phone Number*

Number of Employees*

Entering Group *

(select one)
partial group
full group

If Partial Group, what part is applying and why?

Additional information may be required for partial groups. An application for partial groups shall not be considered complete until Comptroller's staff certify that all requested information has been provided.

Select Dental Option (select one):

        Unlimited Maximum Plan
        $750 Annual Maximum Plan
        $1,000 Annual Maximum Plan
        $1,500 Annual Maximum Plan
        Undecided/Not applicable

Dental HMO can be offered in conjunction with any of the above options. Do you intend to offer the Dental HMO Option?


Will you offer the vision rider?


Member Breakdown*

Please note how many of each member type you are bringing to the plan.

Active Employee

Active +1

Active + Family

Pre-65 Retiree

Pre 65 Retiree + Family

Medicare Retiree

Medicare Retiree + Family

Post-65 Retiree
Not Eligible for Medicare

Post-65 Retiree +1
Not Eligible for Medicare

Post-65 Retiree + Family
Not Eligible for Medicare

Final Step* 

I acknowledge that I have sufficient permission to complete this enrollment application.
Please enter Yes or No.