Become a Partner Contact Information First Name Last Name Company Name Company street address Unit/suite City StatePlease select... AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip code Email Address Phone Number Staff & structure How many employees do you have total?Please select... 0-20 21-50 51-100 101+ # of Sales AssociatesPlease select... 0-20 21-50 51-100 101+ # of Account ManagersPlease select... 0-20 21-50 51-100 101+ # of UnderwritersPlease select... 0-20 21-50 51-100 101+ About the company How many opportunities can you generate annually? Do you represent any competing programs (ie Benefits Captives)? How much of your business is in the 20-500 market? Fully-Insured Please enter as a percent Level-funded Please enter as a percent Self-funded Please enter as a percent Working with Benecon Please list any other information for us in the space below. Please prove that you're not a spambot. What's 1+2? reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA.