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Desired Effective Date
Number of Full-Time Employees
What benefits are you interested in?
Group Major Medical
Group Dental & Vision Insurance
Group Life & Disability Insurance
Group Cancer, Accident & Critical Illness
401(k) Retirement Plan
Group Contact Information
Company Contact Name
Company Contact Email
District of Columbia
American Association of Orthopedic Surgeons
Associates Benefits Group
American Culinary Federation
American Osteopathic Association
American Medical Student Association
American Psychological Association
Arkansas Bar Association
BIC (Beauty Industry Council)
Buy Instant Dental
California Society of Enrolled Agents
District of Columbia Bar
Delaware Association of Realtors
Elite Beauty Society
Florida Health Choices
Florida Medical Association
Florida Petroleum Marketers Associat
Florida Retail Federation
Georgia Home Furnishings Association
Georgia Retail Association
Golf Writers Association of America
Illinois Funeral Directors Association
Intl. Furnishings and Design Association
Jacksonville Bar Association
Massage Magazine Insurance Plus
Louisiana State Bar Association
New Jersey Society of Certified Public Accountants
Ohio State Bar Association
Pennsylvania Institute of CPAs
SPARK Association of Real Estate Professionals
State Bar of Georgia
State Bar of Nevada
State Bar of Texas
The Chicago Bar Association
The Florida Bar
The Missouri Bar
Washington State Bar Association
Private Health Exchange Agreement
I warrant that I am a member of the participating Association. I understand that Member Benefits will not accept my application for coverage, if my eligibility cannot be verified.
Min Group Disclaimer
I understand; to qualify for a small group health plan, my group must meet the following qualifications: In addition to myself (owner), our business has at least one (1) additional non-spouse, full-time W-2 employee listed on my quarterly wage and tax document and enrolling in the plan. A minimum of 70% of all full-time eligible employees may be required to enroll in the group plan, unless a valid waiver is accepted. In addition, a minimum employer contribution of 50% of the cost coverage may be required for all covered employees. All requirements are subject to carrier guidelines and approval. I understand some states and insurance carriers have different requirements for minimum group size, minimum participation, and minimum employer contribution ratios.
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