You are here because your employer has asked you to complete a questionnaire. This information is confidential and is to be used only for the purpose of preparing accurate health insurance proposals for your employer. You will be submitting personal medical information. Your information will be emailed to our office. You will need to provide a valid email address for our office to receive this information. Please answer all questions completely. If you do not answer the required fields and try to submit the form, there will be an error message and you will need to start the process again.

I hereby grant authority to NBI & Associates, LLC and the insurance carriers to release my personal medical information for the sole purpose of acquiring insurance bids. Any other use of this information by any other party not disclosed here is strictly prohibited.

By pressing the "YES" below you are agreeing to the above statements. Also, you are agreeing that the information you provide is for you and your dependants and that all information is accurate to the best of your knowledge.