Form

Ready to discover better benefits for your business?

See how we can help you achieve your goals. Fill out the form below, and one of our experts will get in touch with you soon!

First Name*

Last Name*

Email*

Phone Number*

🇺🇸

🇦🇫 Afghanistan (‫افغانستان‬‎) +93
🇦🇱 Albania (Shqipëri) +355
🇩🇿 Algeria (‫الجزائر‬‎) +213
🇦🇸 American Samoa +1684
🇦🇩 Andorra +376
🇦🇴 Angola +244
🇦🇮 Anguilla +1264
🇦🇬 Antigua and Barbuda +1268
🇦🇷 Argentina +54
🇦🇲 Armenia (Հայաստան) +374
🇦🇼 Aruba +297
🇦🇺 Australia +61
🇦🇹 Austria (Österreich) +43
🇦🇿 Azerbaijan (Azərbaycan) +994
🇧🇸 Bahamas +1242
🇧🇭 Bahrain (‫البحرين‬‎) +973
🇧🇩 Bangladesh (বাংলাদেশ) +880
🇧🇧 Barbados +1246
🇧🇾 Belarus (Беларусь) +375
🇧🇪 Belgium (België) +32
🇧🇿 Belize +501
🇧🇯 Benin (Bénin) +229
🇧🇲 Bermuda +1441
🇧🇹 Bhutan (འབྲུག) +975
🇧🇴 Bolivia +591
🇧🇦 Bosnia and Herzegovina (Босна и Херцеговина) +387
🇧🇼 Botswana +267
🇧🇷 Brazil (Brasil) +55
🇮🇴 British Indian Ocean Territory +246
🇻🇬 British Virgin Islands +1284
🇧🇳 Brunei +673
🇧🇬 Bulgaria (България) +359
🇧🇫 Burkina Faso +226
🇧🇮 Burundi (Uburundi) +257
🇰🇭 Cambodia (កម្ពុជា) +855
🇨🇲 Cameroon (Cameroun) +237
🇨🇦 Canada +1
🇨🇻 Cape Verde (Kabu Verdi) +238
🇧🇶 Caribbean Netherlands +599
🇰🇾 Cayman Islands +1345
🇨🇫 Central African Republic (République centrafricaine) +236
🇹🇩 Chad (Tchad) +235
🇨🇱 Chile +56
🇨🇳 China (中国) +86
🇨🇴 Colombia +57
🇰🇲 Comoros (‫جزر القمر‬‎) +269
🇨🇩 Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo) +243
🇨🇬 Congo (Republic) (Congo-Brazzaville) +242
🇨🇰 Cook Islands +682
🇨🇷 Costa Rica +506
🇨🇮 Côte d’Ivoire +225
🇭🇷 Croatia (Hrvatska) +385
🇨🇺 Cuba +53
🇨🇼 Curaçao +599
🇨🇾 Cyprus (Κύπρος) +357
🇨🇿 Czech Republic (Česká republika) +420
🇩🇰 Denmark (Danmark) +45
🇩🇯 Djibouti +253
🇩🇲 Dominica +1767
🇩🇴 Dominican Republic (República Dominicana) +1
🇪🇨 Ecuador +593
🇪🇬 Egypt (‫مصر‬‎) +20
🇸🇻 El Salvador +503
🇬🇶 Equatorial Guinea (Guinea Ecuatorial) +240
🇪🇷 Eritrea +291
🇪🇪 Estonia (Eesti) +372
🇪🇹 Ethiopia +251
🇫🇰 Falkland Islands (Islas Malvinas) +500
🇫🇴 Faroe Islands (Føroyar) +298
🇫🇯 Fiji +679
🇫🇮 Finland (Suomi) +358
🇫🇷 France +33
🇬🇫 French Guiana (Guyane française) +594
🇵🇫 French Polynesia (Polynésie française) +689
🇬🇦 Gabon +241
🇬🇲 Gambia +220
🇬🇪 Georgia (საქართველო) +995
🇩🇪 Germany (Deutschland) +49
🇬🇭 Ghana (Gaana) +233
🇬🇮 Gibraltar +350
🇬🇷 Greece (Ελλάδα) +30
🇬🇱 Greenland (Kalaallit Nunaat) +299
🇬🇩 Grenada +1473
🇬🇵 Guadeloupe +590
🇬🇺 Guam +1671
🇬🇹 Guatemala +502
🇬🇳 Guinea (Guinée) +224
🇬🇼 Guinea-Bissau (Guiné Bissau) +245
🇬🇾 Guyana +592
🇭🇹 Haiti +509
🇭🇳 Honduras +504
🇭🇰 Hong Kong (香港) +852
🇭🇺 Hungary (Magyarország) +36
🇮🇸 Iceland (Ísland) +354
🇮🇳 India (भारत) +91
🇮🇩 Indonesia +62
🇮🇷 Iran (‫ایران‬‎) +98
🇮🇶 Iraq (‫العراق‬‎) +964
🇮🇪 Ireland +353
🇮🇱 Israel (‫ישראל‬‎) +972
🇮🇹 Italy (Italia) +39
🇯🇲 Jamaica +1876
🇯🇵 Japan (日本) +81
🇯🇴 Jordan (‫الأردن‬‎) +962
🇰🇿 Kazakhstan (Казахстан) +7
🇰🇪 Kenya +254
🇰🇮 Kiribati +686
🇽🇰 Kosovo +383
🇰🇼 Kuwait (‫الكويت‬‎) +965
🇰🇬 Kyrgyzstan (Кыргызстан) +996
🇱🇦 Laos (ລາວ) +856
🇱🇻 Latvia (Latvija) +371
🇱🇧 Lebanon (‫لبنان‬‎) +961
🇱🇸 Lesotho +266
🇱🇷 Liberia +231
🇱🇾 Libya (‫ليبيا‬‎) +218
🇱🇮 Liechtenstein +423
🇱🇹 Lithuania (Lietuva) +370
🇱🇺 Luxembourg +352
🇲🇴 Macau (澳門) +853
🇲🇰 Macedonia (FYROM) (Македонија) +389
🇲🇬 Madagascar (Madagasikara) +261
🇲🇼 Malawi +265
🇲🇾 Malaysia +60
🇲🇻 Maldives +960
🇲🇱 Mali +223
🇲🇹 Malta +356
🇲🇭 Marshall Islands +692
🇲🇶 Martinique +596
🇲🇷 Mauritania (‫موريتانيا‬‎) +222
🇲🇺 Mauritius (Moris) +230
🇲🇽 Mexico (México) +52
🇫🇲 Micronesia +691
🇲🇩 Moldova (Republica Moldova) +373
🇲🇨 Monaco +377
🇲🇳 Mongolia (Монгол) +976
🇲🇪 Montenegro (Crna Gora) +382
🇲🇸 Montserrat +1664
🇲🇦 Morocco (‫المغرب‬‎) +212
🇲🇿 Mozambique (Moçambique) +258
🇲🇲 Myanmar (Burma) (မြန်မာ) +95
🇳🇦 Namibia (Namibië) +264
🇳🇷 Nauru +674
🇳🇵 Nepal (नेपाल) +977
🇳🇱 Netherlands (Nederland) +31
🇳🇨 New Caledonia (Nouvelle-Calédonie) +687
🇳🇿 New Zealand +64
🇳🇮 Nicaragua +505
🇳🇪 Niger (Nijar) +227
🇳🇬 Nigeria +234
🇳🇺 Niue +683
🇳🇫 Norfolk Island +672
🇰🇵 North Korea (조선 민주주의 인민 공화국) +850
🇲🇵 Northern Mariana Islands +1670
🇳🇴 Norway (Norge) +47
🇴🇲 Oman (‫عُمان‬‎) +968
🇵🇰 Pakistan (‫پاکستان‬‎) +92
🇵🇼 Palau +680
🇵🇸 Palestine (‫فلسطين‬‎) +970
🇵🇦 Panama (Panamá) +507
🇵🇬 Papua New Guinea +675
🇵🇾 Paraguay +595
🇵🇪 Peru (Perú) +51
🇵🇭 Philippines +63
🇵🇱 Poland (Polska) +48
🇵🇹 Portugal +351
🇵🇷 Puerto Rico +1
🇶🇦 Qatar (‫قطر‬‎) +974
🇷🇪 Réunion (La Réunion) +262
🇷🇴 Romania (România) +40
🇷🇺 Russia (Россия) +7
🇷🇼 Rwanda +250
🇧🇱 Saint Barthélemy (Saint-Barthélemy) +590
🇸🇭 Saint Helena +290
🇰🇳 Saint Kitts and Nevis +1869
🇱🇨 Saint Lucia +1758
🇲🇫 Saint Martin (Saint-Martin (partie française)) +590
🇵🇲 Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon) +508
🇻🇨 Saint Vincent and the Grenadines +1784
🇼🇸 Samoa +685
🇸🇲 San Marino +378
🇸🇹 São Tomé and Príncipe (São Tomé e Príncipe) +239
🇸🇦 Saudi Arabia (‫المملكة العربية السعودية‬‎) +966
🇸🇳 Senegal (Sénégal) +221
🇷🇸 Serbia (Србија) +381
🇸🇨 Seychelles +248
🇸🇱 Sierra Leone +232
🇸🇬 Singapore +65
🇸🇽 Sint Maarten +1721
🇸🇰 Slovakia (Slovensko) +421
🇸🇮 Slovenia (Slovenija) +386
🇸🇧 Solomon Islands +677
🇸🇴 Somalia (Soomaaliya) +252
🇿🇦 South Africa +27
🇰🇷 South Korea (대한민국) +82
🇸🇸 South Sudan (‫جنوب السودان‬‎) +211
🇪🇸 Spain (España) +34
🇱🇰 Sri Lanka (ශ්‍රී ලංකාව) +94
🇸🇩 Sudan (‫السودان‬‎) +249
🇸🇷 Suriname +597
🇸🇿 Swaziland +268
🇸🇪 Sweden (Sverige) +46
🇨🇭 Switzerland (Schweiz) +41
🇸🇾 Syria (‫سوريا‬‎) +963
🇹🇼 Taiwan (台灣) +886
🇹🇯 Tajikistan +992
🇹🇿 Tanzania +255
🇹🇭 Thailand (ไทย) +66
🇹🇱 Timor-Leste +670
🇹🇬 Togo +228
🇹🇰 Tokelau +690
🇹🇴 Tonga +676
🇹🇹 Trinidad and Tobago +1868
🇹🇳 Tunisia (‫تونس‬‎) +216
🇹🇷 Turkey (Türkiye) +90
🇹🇲 Turkmenistan +993
🇹🇨 Turks and Caicos Islands +1649
🇹🇻 Tuvalu +688
🇻🇮 U.S. Virgin Islands +1340
🇺🇬 Uganda +256
🇺🇦 Ukraine (Україна) +380
🇦🇪 United Arab Emirates (‫الإمارات العربية المتحدة‬‎) +971
🇬🇧 United Kingdom +44
🇺🇸 United States +1
🇺🇾 Uruguay +598
🇺🇿 Uzbekistan (Oʻzbekiston) +998
🇻🇺 Vanuatu +678
🇻🇦 Vatican City (Città del Vaticano) +39
🇻🇪 Venezuela +58
🇻🇳 Vietnam (Việt Nam) +84
🇼🇫 Wallis and Futuna +681
🇾🇪 Yemen (‫اليمن‬‎) +967
🇿🇲 Zambia +260
🇿🇼 Zimbabwe +263

How did you hear about us?*

Brian Thomas (WKRC)
Chris Stigal (USMedicalPlans.com)
WLW Radio
IHEARTRADIO (107.1)
ESPN Radio (Mo Egger)
John Ruhlman Podcast (Rethink Healthcare Together)
Website
Office Road Sign
Road Sign (Ad)
Walk In
Networking Event
Spoke to an Agent
Friend/Family Referral
Referral Partner
Google/Bing/Google Maps
Facebook
Instagram
YouTube
Direct Mail
Kiosk- (Kroger/Kenwood Mall)
HealthCare.gov
LinkedIn

1/3

Company name

Number of Employees

Street Address

City

State/Region

Postal Code*

1/3

Do you currently have insurance coverage?

Yes

Current Insurance Carrier

What states do your employees live in?

Cost of plan per month per employee? Is that Individual or Family?

Do you contribute to the payment of the employee’s premiums? If so, what is the percentage or dollar amount you contribute?

What would you like the proposed Effective Date to be for the new coverage?

Product Topics you would like to discuss during your meeting:

Health Insurance

Life Insurance

Medicare Supplements

Medicare Advantage Plans

Prescription Drug Plans

Long Term Care

Disability

Critical Illness

Hospital Indemnity Plans

Dental, Vision, Hearing

Employee Benefits

We are committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

I agree to receive other communications from USABG A-Team.

You may unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.

By clicking submit below, you consent to allow American Brokerage Solutions to store and process the personal information submitted above to provide you the content requested.

1/3