To contact us by phone, please call Jay Barnes, VP - Business Development at 1.800.4.FORTIS, ext. 229 or via email at jay@jlbghealth.com

To contact us via the internet, please complete the automated short form below.

Contact & Personal Information

Association Name:
First Name:
Last Name:
Work Phone:
Email:
Association Web Site:
Address:
City:
State:	Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -----------------------------
Zip Code:
.	...
Services Requested:     Customer Service Mass Mailing Billing Membership ID Cards Printing Of Materials On-line Only Association Commissions Accounting Mass Mailing Options:     Mass e-Mailing NONE Monthly Quarterly Yearly Mass Mailing  NONE Monthly Quarterly Yearly ...
Tell us about your association and the type of benefits you are interested in offering your membership.
How many members does your association have?:
Is your association national?:	Yes  No
Is your membership mainly individual or corporate based?:	Individual  Company  Other
Do you currently provide members with health benefits and other ancillary insurance products (dental, ltd, life)?	Yes  No
What type of benefits would you like to provide your members with?: