CLIENT INFORMATION FORM

Benefit Indemnity Corporation uses the Self-Funded Exchange Marketplace in order to get the best possible medical coverage at the best price. With the Self-Funded Exchange Marketplace, you’ll enter your information ONE time rather than filling out multiple paper applications. Since your information is stored securely from year to year, next time, you’ll only have to verify your information and make any updates.

This form is split into several sections/pages for easier viewing and completion. If you login using a Google account, your progress will be saved, but you must click SUBMIT on the final page to SEND for completed form to BIC.  Required fields are indicated (*), but completing the optional fields is highly encouraged.

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Broker Name *
Broker Email Address *
Agency Name *
Work Phone Number *
Mobile Phone Number
Fax Number
Work Street Address *
Work City *
Work State *
Work Zip *
Who would you like the Welcome Letter sent to?  (select all that apply) *
Required
Quoting Broker Information
Please complete only if different than "Broker on Record" above.
Quoting Broker Name
Quoting Broker Phone
Quoting Broker Email
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