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.

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Required fields are indicated (*), but completing the optional fields is highly encouraged.

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