516- 414- 1927
BizHealthIns.com
Creative Solutions to Lower Your Company's Health Care Cost
Servicing New York City's 5 Boroughs & Long Island
Your Name:
Company Name:
Address:
City,State Zip Code:
County:
Phone Number:
Fax Number:
Email Address:
Current Insurance Carrier:
Renewal Date:
Current Insurance Carrier:
 Renewal Date:
Number of eligible employees (working
min. 20hrs. per/wk earning min. wage):
Number of Employees Participating in Plan:
YES
NO
Do any of the participating employee's live outside  N.Y. State?
Of the participating employee's, indicate the number of each to be insured:
Employee &
Spouse:
Employee &
Child(ren):
Singles:
Family:
Comments:
Additional Info.
Business Health Benefits Plus, LLC
PO Box 25
Franklin Square, NY 11010

sales@businessbenefitsolutions.com

tel.        515-414-1927
tel.        516-528-1084

fax       516-486-8212