 You
may download the form by clicking on the above link. Your
browser should automatically open up your Adobe Acrobat
Reader. If you need to get the Acrobat Reader, please
click
here.
You
may then print and fill out the form.
Please send all completed forms along with your check,
to your broker or to:
LIA
Health Alliance
Enrollment Processing Center
1717 Veterans Memorial Highway, Suite 4
Islandia, NY 11749
If
you have any questions, please call 1-800-LIA-5513 |
