Health Benefits
Risk Management
and Administration



Information Request Form
(* Required fields)

Number of FTEs*:
Current TPA / insurance carrier*:
Renewal date of health insurance / benefit plan*:
 
Do you have a broker / consultant?*
No Yes
  (If Yes, please answer the following):
Broker / consultant name:
E-mail:
Phone:
 
Is your organization*:
Self-insured Fully insured
Who is your benefit plan decision maker?
Name:
Title:
 
Personal Information:  
Contact Name*:
Organization*:
Address*:
City*:
State*:
Zip*:
E-mail*:
Phone*:

SIBA

Street Address:
2600 McCormick Drive, Ste 370
Clearwater, FL 33759

Mailing Address:
P.O. Box 9077
Clearwater, FL 33758-9077

800.683.SIBA (7422)
727.532.0400