Information Request for Individuals and Families

Thank you for your interest in insurance products and services for individuals and families.  For more specific information please fill out and submit the form below to receive additional information. 

If you choose, a representative of BIS Benefits will contact you to further discuss your needs. 

Information provided on these forms will be confidential and used only to provide the material requested.

* required fields

Your Name*:
Title:
Date of Birth*:
Gender*:	Male Female
Spouse's Name
Dependant(s) Name & Dates of Birth
Street Address:
City:
State:	Choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Newfoundland North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming
Zip Code*:
Telephone:
Facsimilie:
e-Mail*:
Areas of Interest: (click all that apply)	Medical (apply online for a free quote) Dental Vision Life & AD&D Disability If interested in Life or Disability, please provide the following: Annual Salary Job Title Average Yearly Income (based on previous 2 years) Key Person Insurance Payroll Deduction Programs Section 125/Cafeteria Plans 401(k) & 403(b) Retirement plans
	SEND KEY Please carefully type the characters on the left side into the empty box on the right. * : (This has been implemented to prevent unauthorized automated scripts.)