Benefits Contact Information
*
First Name
Last Name
Email
*
Phone Number
*
Title
Company name
*
Company address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Requested date of effective coverage
*
-
Month
-
Day
Year
Date
Number of full time employees (including owner)
*
Number of employees currently enrollment in health plan
*
Licensed medical professionals
*
Number of employees holding licenses issued by the board of medical examiners or dentistry
Does your business work with a broker?
*
Yes
No
Works with broker (pass-through)
Yes
Would you like to work with an APHT-preferred broker?
Yes
No, thanks
Broker name
First Name
Last Name
Agency name
Broker email
example@example.com
How'd you hear about us?
Please Select
LSMS advertisement
Friend/colleague
Broker
Web search
Broker Details
Contact me
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