BioFlex | Lead Intake Form

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Thank you for your interest in BioFlex. Please complete this form to help us determine if BioFlex is a good fit for your organization. Fields marked with * are required.

IMPORTANT QUALIFICATION CRITERIA:
- Must have W2 employees
- Minimum 10 full-time W2 employees
- Employee age range must be 18-70
- Business must be based in the US
Do you have W2 Employees?*

YesNo
Number of W2 employees?*
Minimum of 10 employees required.
What are your primary challenges with employee benefits? (select all that apply)*

Rising costsEmployee retentionLimited benefit optionsAdministrative burdenOther (please specify)
Business Address (US-Based Businesses Only)*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Your Name*

First NameLast Name
Best Phone Number
Please enter a valid phone number.
Best Email*
example@example.com
Business Name*
e.g. Together Financial LLC
Please describe the product/service your company sells.*
Type of Business (Select One)*

Retail StoreRestaurant/Food ServiceService/Repair ShopService BusinessOnline/E-commerceHealthcareProfessional ServicesOther (please specify)
Validate Your Phone

We need to make sure you are a real person! Please enter the same number as above to receive a code to enter to complete your application.
Validate Your Phone*
Should be Empty:

Validate Your Phone