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Association Health Plans save members on major medical, dental and supplemental coverage. We have harnessed the power of your membership to provide access to great prices on benefits for you, your staff, and your dependents.

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Lead Record Type

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Source Account ID

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Post ID

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Practice Information

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Salesforce ID

Name*

First Last

Email Address*

Phone*

Legal Name of Operation*

Your Website

City*

State*

5-Digit Zip Code*

Please enter a number from 00500 to 99999.

Number of full-time employees*

Number of part-time employees

Number of 1099 employees

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Number of Employees*

Product Interest

What products are you interested in?

Medical, Dental and Supplemental/Ancillary Benefits

HR Services (Recruiting, E-Verify®, document management, HR Helpline)

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Emp Bens

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ARP

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PNC

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Additional Information

Which of the following payroll providers do you use?*

Other provider? Please specify:*

Do you have group insurance?*

Yes

Who is your current medical carrier?*

Other medical carrier:*

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Approximately how many employees are enrolled?*

What is your coverage renewal month?*

Best Time to Call

We're looking forward to speaking to you about your product interests. Please select a time range that is most convenient for us to reach out to you.

Time Preference*

I have no preference on time.

I'd like to select a time that works best for me.

Time Range*

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Lead Source Detail

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Lead Source

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Lifecycle Status

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Channel

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Type of Referral

Comments

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