Your Financial Subsidy
Proposal Request

For All Communities

Preparing Your Financial Subsidy Proposal

Welcome:  Here's a few things you need to know. We respect your privacy.  We won't ask you for your name or contact information to give you a Proposal.  Also, Your responses will be confidential and will not be disclosed to anyone outside CHC.

Directions:  Click the Step 1 Blue Banner and that section will open.  Answer a few questions and move to the next Step.  The more information you can provide will help us prepare your Proposal.  When Completed, Click the "Send Us Your Proposal Form" HUG.

Thanks for your interest and participation.
Click Step 1 to begin.

Please describe your Community’s healthcare situation for each of the following:

The number of Medical Providers within your Community’s boundary:

How many employers are within the boundary of your Community?

If you do not have a current healthcare plan, enter "None" in the Insurance Company Name field.


If You Currently Have a Healthcare Plan

$
$
To Receive a Healthcare Plan Quote

Please enter the number of staff affiliated with your Company by classification:

Please enter the number of your Company’s Affiliates in each Age Tier:

* The number of staff affiliated with your Company

* The number of staff currently on your Company's Healtcare Plan

Additional Information:

$

What Would You Like To Do Next?