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Benefit Administrators, Inc.

provides cost-effective benefit

plans and administrative

services for a broad spectrum

of clients.


We pride ourselves on

customer care and have the

ability to tailor our services.

We offer both group and

individual plans from

quality insurance carriers.
Individual Quote   (Printable Version)

Date:

Primary Applicants Name:

Smoker: Yes No

Date of Birth:

City: ZIP:

Occupation:

Spouse Date of Birth:

Smoker: Yes No

Occupation:

Number of Children:

Preferences

Deductible:

Coinsurance:

Optional Benefits

Maternity: Yes No

Office Visit Copay: Yes No

Supplemental Accident Benefit: Yes No

Prescription Drug Card: Yes No

Effective Date: (Please allow at least 30 days to process your application)

Medical Conditions and/or Medications
(Please be as detailed as possible. Some conditions may result in the inability to obtain individual coverage through one or more of the carriers used.)

Applicant:


Spouse:


Child(ren):


How to Reach You

Phone:

Fax:

E-mail:

Address:

City: State: ZIP:


©2007 Benefit Administrators | 14214 U Street | Omaha, NE 68137 | 402-896-0661 | Fax: 402-896-1451 | info@benefit-administrators.com