Employee Benefits Division Membership

Employee Benefits Division

Membership Application
Company Name:
Full Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.

Type of Membership

Health Agent (single employee)- For a single individual, the cost is $250/year.Agency Membership- $250/year for 1 licensed employee. Then $100 per licensed employee to a maximum of $2500.00/year

If you have selected the Health Agent membership (single employee), the first page of this application is the only necessary section to complete. Just click "Next"

If you selected the Agency Membership (several members from one location), please supply a detailed list of each producer in your organization below.

Employee 1
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Employee 2
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Employee 3
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Employee 4
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Employee 5
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Thank you for taking the time to fill out this application! Just hit the "Submit" button below and we'll be in touch shorlty.
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