Business Underwriters Associates, LLC
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CLIENT INFORMATION
Group Name *
Nature of Business *
County
City *
State *
-- Select 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
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip / Postal Code *
Total Number of Full Time Employees
Total Number of Part Time Employees
Weekly Hours to be Considered Full Time
Number of Participating Employees
Number of Waiving Employees
PRODUCTS REQUESTED
Current Insurance Carrier
Current Health Insurance Plan Type
PPO
HMO
HDHP
Fully Insured
Partially Self Insured
Fully Self Insured
Renewal Date
Health Insurance
Yes
No
Dental Insurance
Yes
No
Vision Insurance
Yes
No
Life Insurance
Yes
No
Short Term Disability Insurance
Yes
No
Long Term Disability Insurance
Yes
No
Accident Insurance
Yes
No
Critical Illness Insurance
Yes
No
ADDITIONAL INFORMATION
ADVISOR INFORMATION
Advisor Name *
Advisor Phone Number *
Advisor Email Address *