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?

                                      Yes    
           No

Will you offer the vision rider?

          Yes
                                    No

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.