Client Information Form

Benefit Indemnity Corporation uses the Self-Funded Exchange Marketplace in order to get the best possible medical coverage at the best price. With the Self-Funded Exchange Marketplace, you’ll enter your information ONE time rather than filling out multiple paper applications. Since your information is stored securely from year to year, next time, you’ll only have to verify your information and make any updates.

This form is split into several sections/pages for easier viewing and completion. If you login using a Google account, your progress will be saved, but you must click SUBMIT on the final page to SEND the completed form to BIC.  

To Begin, Click the Button Below to Complete ALL PAGES of the Google Form.
Required fields are indicated (*), but completing the optional fields is highly encouraged. Please Note: all "optional" fields should still contain text, therefore there are currently placeholders typed into them. Please do not delete UNLESS you are completing that field with valid information. Thank You!

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