MHC is excited to partner with WEX on the administration of your medical spending accounts and look forward to working with you!
 
In an effort to make sure you are provided necessary information regarding your benefits the following information is needed. MHC & WEX will utilize this information to ensure you are notified of upcoming events that affect participant and group accounts.
 
Please complete and submit this form by 5/16/2022.

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* 1. Group Information:

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* 2. Which Service Cooperative are you affiliated with?

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* 3. Who is the primary contact for your medical spending accounts? (This is often a payroll or HR staff member)

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* 4. Do you work with an Insurance Agent or Consultant? (If no agent or consultant, leave blank)

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* 5. In order to access tools and resources related to your transition to WEX, the email domains your organization uses will need to be added to our system.  Please provide a list of any domains that your organization/consultant teams use that we should list on file: (Example: @company.com)

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* 6. Total number of employees eligible for health insurance benefits:

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* 7. Total number of employees that participate in health insurance benefits:

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* 8. Do you have a payroll vendor you would like WEX to build an automated file integration with?  If so, please provide their information, below:

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* 9. Do you have a current enrollment or benefits administration vendor you would like WEX to build an automated file integration with?  If so, please provide their information, below:

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* 10. Do you currently utilize WEX for any services?

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