Contact form for Association Health Plans

Health Plan Information Request Form:

Thank you for contacting us regarding these new and exciting plans. We would like for you to complete the short form below and someone from Sandbrook Group will contact you shortly. We look forward to exploring these new plans and working with you to provide an excellent benefit to you and your staff.
Full Name *

First Name Last Name
Business Info: *

Business Name

Address

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail
What type of Employee Benefits do you currently offer?:

Medical Dental Vision Life Disability None
I agree that if I determine the Association Health Plan would be a benefit to my company, and if I decide to enroll, I will contract with Sandbrook Group as my Broker of Record.

Yes No
How did you hear about us? *
Should be Empty:

Health Plan Information Request Form: