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Alaskan Benefit Insurance Consultants

Spencer Biegel dba  
Alaskan Benefit Insurance Consultants  
907-243-1488 Fax 243-1411  
4225 Trapline Drive  
Anchorage, AK 99516-1536  

abic@customcpu.com  




INDIVIDUAL OR FAMILY FORM

Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

Name: *
Address *
City *
 State
 		Zip Code *
Phone *
 Fax:
E-mail Address *
*
M    F   
DOB MM-DD-YY: *
 Smoke... *
Yes    No   
Height X'& X": *
 Weight: *
Major Health Conditions or medications for all family members?:
Spouse Info:
M    F   
DOB MM-DD-YY:
 Smoke...
Yes    NO   
Height:
 Weight:
Children DOB'S MONTH / YEAR SEX M/F:
Deductible:
500 to 5,000    1,000 to 25,000   
Variety of choices    HSA DEDUCTIBLES   
Desired Effective Date MM/YEAR: *
Type of Insurance Desired: Check all that apply.
Health Savings Account HSA    Maternity    Dental    Vision   
Disability    Life    Supplemental Accident    Long Term Care   
Medicare Supplement    International Health Plans    HEALTH INSURANCE    Annuity   

* Required to submit this form












Alaskan Benefit Insurance Consultants

(907) 243-1488 FAX 243-1411 EMAIL abic@customcpu.com

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