Client Information Form

Broker Information

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.

Complete the Form Below to Begin.
Required fields are indicated (*), but completing the optional fields is highly encouraged.

NOTE: Depending on your screen size, this form may cut off at the bottom.
To get the next field or button to appear, click the "TAB" key on your keyboard to move through the fields on the form.

Broker on Record:

The information entered will create or update the broker record in our contact database.
Please be sure this information is accurate in order to keep you record accurate in our system.

First Name *
Last Name *

Email *

PLEASE ONLY USE YOUR OWN EMAIL ADDRESS!
Our system is based on email address. If you use someone else's email address with
your name, they will no longer exist in our system and you will have multiple records.

Agency Name *

Work Street Address *
Work City *
Work State *
Work Postal Code *

Phone1 (type)
Phone1 # *

Phone2 (type)
Phone2 #

Fax #

Who would you like the Welcome Letter sent to? *

Me, the BrokerMy Client, the EmployerBoth