Get the free Ohio Master Application - Paramount Health Care
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Small Group Master Application
Business Name: ___ Requested Effective Date: ___
Address: ___ City: ___ Zip:___
Phone Number: (___) ___ Fax: (___) ___
SIC/Primary Business Activity: ___ Years in Business: ___
Contact Person: ___
Email address of Contact Person:___
Please provide the following information relating to your current and previous health insurers:
Current Carrier: ___ Number of years with current carrier: ___
Plan Type (deductible/coi
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