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* 1. Contact Name

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* 2. Email

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* 3. Name of Business

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* 4. Is your business a member of a participating Chamber or organization?

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* 5. What Chamber do you belong to?

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* 6. Number of employees

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* 7. What kind of Peak Health Alliance insurance product did your group enroll in?

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* 8. When did you start health insurance coverage for your group?

Date

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* 9. To receive your rebate, you must send proof of enrollment to Peak. Please send proof of enrollment for your group to elise@peakhealthalliance.org. Please select the box below to indicate that you understand this requirement and will send documentation to Elise at Peak.
Examples of proof of coverage: Bill from ICHRA platform, premium bill if level-funded, etc.

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* 10. To complete this form and receive your rebate, provide your complete mailing address information below. Your rebate check will be mailed to you directly from Peak Health Alliance.

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