Requirements of Sold Business
- Original completed Employer Application (46KB PDF)
- Original completed Employee Enrollment Forms (51KB PDF)
- Most current wage and tax statement
- Most current monthly premium statement of the medical insurance carrier
- A copy of the employer’s policy or SPD for medical coverage, showing the waiting period and the number of working hours required to be a full-time, covered individual
- Binder check with first month’s premium
- Copy of the proposal presented
All Originals Must be Sent to the Underwriting Department at SecureScript.
Do not cancel current coverage until a written verification letter has been received confirming the rates, plan design and effective date.
PO Box 2997
Grand Rapids , MI 49501-2997
Phone: (616) 454-3157
Toll Free: (866) 718-7701
Fax: (616) 454-4338
Underwritten by Fidelity Security Life Insurance Company, Kansas City, MO