VMA Group Benefits Request Form
Please complete this form and a VMA Insurance Services Representative will contact you directly to set up a consultation.
Number of Employees Enrolled
Please select all of the VMA Insurance Services of interest to your company *NOTE: For Medical and Dental, companies must submit a census and wait until July 1, 2019 for potential coverage.
Disability (short and long term)
Consumer benefits (accident/critical illness)
Should be Empty: