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BeneNet Application

You may complete this form on-line and submit it via this web site. You will need to fill out the census or email one where indicated.

You may also print a PDF version of this form and return it by fax or mail with your Employee Census. All questions must be answered to proceed to page two.

Fax to:
NVTC BeneNet
fax: 703.777.2668

Mail to:
NVTC BeneNet
20 South King Street
Leesburg, VA. 20175

E-mail to: NVTC BeneNet

Company name:
Company Address:  
Street:
City:
State     Zip    
Phone Number:
Is this headquarters
location?		 Yes    No
Description of your business:
Number of Employees: Please note: There must be two or more employees.
All Company Locations: To select more than one state, hold down the ctrl key and make your selections.
 
Contact name:
Contact E-mail:
This is the email address to which we will send a copy of this RFP, as well as the quote itself.

Employee Benefit Coverage Options
Please select the coverage you wish quoted. You will only see further information and questions relating to the options you have selected. You may wish to select two options to compare the cost difference.

Medical Yes    No
Dental Yes    No
Life Yes    No
Short Term Disability Yes    No
Long Term Disability Yes    No
Vision Yes    No
Travel Accident Yes    No
401k Yes    No

Have a question?
Click here to send it.

Apply Online.
Click here to receive a proposal for insurance coverage.

Program Managing Partner:
AH&T Insurance
703-777-2341
800-648-4807

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