Company Name:
Address:
City:	State: Zip:
Phone:	Fax:

Insurance Contact Person in your Organization:

If available, would you be interested in accessing your insurance records via the internet? (ie – billing, claims & coverage)

Yes No

Important Email Addressess:	(ie – billing, claims, coverage)
Email 1:
Name:	Position:
Email 2:
Name:	Position:
Email 3:
Name:	Position:

Number of Full Time Employees:

Number of Part Time Employees:

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(We will never send any unsolicited Email.)