Colorado Mountain College Employees
Product Information Request Page
Part Time Employees and Adjunct Faculty

(working on average 20 hours or more per week
or teaching seven credit hours or more per semester)
Employee Information Employee Name
Work Location
Job Title
Mailing Address
 
City
State        Zip 
Day Phone
Eve Phone (optional)
E-Mail Address
My Birthday is:
My Spouse's Birthday is:
Dependent Children Yes No
Insurance Information Requested (check all that apply) Long Term Care Insurance
Colonial Supplemental Insurance
Short Term Disability
Accident
Accident with Disability Rider
Cancer
Hospital Income
Critical Illness
Term Life
Universal Life
Pre-Paid Legal Services
Legal Services Plan
Identity Theft
Dental & Vision Plans
Alpha Dental (Discount Program)
Companion Life Dental Plan (Indemnity Program)
Vision Insurance provided at No Cost with either Dental Plan Selection
Comments/Special Requests

Upon receipt of your request an Insurance and Wellness in the Rockies representative will contact you to provide the appropriate information, a personal quote and/or a private consultation.

You may also contact our office by phone, fax or stop by to set an appointment.
Phone: 970-384-1900 or 800-613-4021
Fax: 970-384-1901 or 800-889-6260
E-Mail:info@insuranceandwellness.com
Address: 817 Colorado Avenue, Suite 106
(Alpine Professional Building next to the Post Office)
Glenwood Springs, CO 81601