"Providing superior, tax advantaged healthcare solutions to the Small and Mid-sized business community."
To get started, please complete ALL the following information.
(Any blank fields will be left out of your application and may delay it's processing)
SBA # (Found on Advertisment) Type and Number of Employees:
Is your current plan fully insured:
W-2: #
1099: #
Full-Time: #
Part-Time: #
Desired new plan design:
Current # of Employees on Your Payroll:
Start date required:
If Other Please Specify: / / (mm/dd/year)
 
Your Personal Contact Info
Business Name: Your Full Name:
Business Address:
City State / Zip: /
Main Phone: Cell Phone:
Email:
The following information is required for you and your family to get started. This information will be needed for each employee that wishes to participate in your customized healthcare program.
Participant DOB (MM/DD/YYYY) Gender Height (ft) Height (in) Weight Tobacco Use 12 Months of Credible Coverage?
Primary (You) / /
Spouse / /
Child 1 / /
Child 2 / /
Child 3 / /
Child 4 / /
Child 5 / /
Child 6 / /
List by participant: Medical Conditions (Past 10 years)
Participant Condition Medical Treatment Received
List by participant: Current Medications (please include EXACT name, dosage, and frequency)
Participant Medication Name Dosage Frequency
Special Instructions, Comments or Questions:

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