Colorado Mountain College Employees
Product Information Request Page
Full-Time Benefit Eligible Employees and Faculty

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
Pre-Paid Legal Services
Legal Services Plan
Identity Theft
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