Health Benefits
Risk Management
and Administration



Information Request Form
(* Required fields)

Number of FTEs*:
Current TPA / insurance carrier*:
Renewal date of health insurance / benefit plan*:
 
Do you have a broker / consultant?*
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  (If Yes, please answer the following):
Broker / consultant name:
E-mail:
Phone:
 
Is your organization*:
Self-insured Fully insured
Who is your benefit plan decision maker?
Name:
Title:
 
Personal Information:  
Contact Name*:
Organization*:
Address*:
City*:
State*:
Zip*:
E-mail*:
Phone*:

BeneSys, Inc.

Street Address:
1745 North Brown Road
Suite 400
Lawrenceville, GA 30043

Mailing Address:
P.O. Box 105738
Atlanta, GA 30348-5738

800.680.8728
678.258.8200