Contact | Benafica

I'm interested in

I am a:*

Are you a:*

Name of Organization*

Name*

First Last

Email*

Phone*

State*

Zip Code

Date of Birth

Gender

Male
Female

Disabled?

Yes
No

I'm interested in:*

Select All
Medicare
Health
Life
Long Term Care
Disability Income
Dental and/or Vision Insurance
Other

For a consultation would you prefer:*

In person
Over the phone
Over the phone with computer screen sharing

Would you like to answer additional questions that may help you choose a plan?

Yes
No

When would you like your coverage to begin

How would you describe your health condition?

Poor
Good
Excellent

Would you need routine medical care if you were traveling out of your home area, or do you travel internationally?

Yes
No

Do you take prescription medications?

Yes
No

What kind of premiums and copayments would you rather plan for?

Lower monthly premiums and higher copayments when you go to the doctor
Higher monthly premiums and minimal copayments when you go to the doctor or hospital?

Interested in:

Employee/Member Benefits
Administration Services

Benefits

Select All
Medicare
Health
Life
Long Term Care
Disability Income
Dental and/or Vision Insurance
Other

Services

Select All
Employer COBRA Administration & Compliance Services
Claims Services
Billing/Payment Services
Form Services
Commission Services

LEO Platform Services of Interest

COBRA Administration
Claims Services
Billing/Payment Services
Forms Services
Commission Services

Comments

How can we help you?*

Add Member*

First Last

Date*

Name*

First Last

Date of Termination*

Termination Cause*

Insurance Carrier Issue*

File

Drop files here or

Describe your issue

CAPTCHA