IBPI Health Plan Interest Form

IBPI Health: Getting Started

Submit the data needed to get a quote!
Company Name *
Contact Name *

First Name Last Name
Contact Phone Number *
Please enter a valid phone number.
Contact Email *
example@example.com
Primary Business Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Time Zone *
How many full-time employees do you have? *
Full-time is usually defined as 30+ hours per week.
Employee Census
Please upload a census of all employees working 30+ hours per week on a regular basis, including owners.

A census template can be found HERE. More information makes quoting easier, so please include as much info as you like, adding additional columns as needed. Please do not include employees who are not benefits eligible.

If you choose to upload your census in your own format, please ensure that following information is included in your spreadsheet, at a minimum:
First name, Last name, Date of Birth, Gender, Date of Hire, Enrollment Status, and Email Address.
Upload your completed census here. *

Cancel of
Do you have a group medical plan in place currently? *

Yes No
When does your current health plan renew? *

Month Day Year
Date
Current Plan Designs and Details

Please upload your current plan designs and rates, most recent renewal, and, if available, recent claims data.
Cancel of
Terms and Conditions
I hereby represent that I am an authorized representative of the participating employer and that the statements and answers to the questions on this enrollment form are true and complete to the best of my knowledge and belief. I understand that the statements and answers contained herein will be used by Anderson Thornton Consultants to determine eligibility for group coverage under the IBPI Health Plan for myself and persons listed on this enrollment form as employees and their dependents.

I understand that (1) the answers given will be the basis of any coverage provided; (2) any material misrepresentation or failure to provide complete information to questions on this and/or subsequent form(s) may be used as a basis for changing rates or terminating coverage; (3) if coverage is not approved, I, my employees, nor their dependents are entitled to benefits; (4) coverage will not be effective until my employer receives notice that enrollment has been approved by the plan administrators.

I understand that this authorization is required in order to enable eligibility or enrollment determinations relating to me, my employees and/or their dependents or for administrators to make underwriting or risk rating determinations. If I refuse to sign this authorization, I may be refused coverage.
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IBPI Health: Getting Started

Terms and Conditions