Health Insurance Information Request:
 
The Michigan Business and Professional Association and Michigan Food and Beverage Association are BCBSM/BCN-sponsored authorized independent associations.  Blue Cross Blue Shield of Michigan and Blue Care Network are independent licensees of the Blue Cross Blue Shield Association.
 Yes, I am interested in receiving a quote on the following:
 BCBSM/BCN group coverage
 Individual Care Blue Coverage
 No, I am not interested at this time, but keep me on your mailing list.
 I am not interested in changing my insurance coverage at this time, but please have the Membership Service Team call me with information about other benefits and services that you offer.
   

Contact Person:

Title:

Company Name:

Membership:

  MBPA member
 MFBA member

 

  Not a member
Phone:

Fax:

Business Address:

City:

State:

Zip:

Email:
 
 Please call my current insurance agent
 I do not have an insurance agent - please have one contact me.

Agent's name:

Phone:
 

Type of coverage:

Business:

  Number of employee:

Individual:
Why are you looking for a quote:
Type of current coverage (PPO, HMO etc):
Name of current provider (PPOM, Care Choice, HAP, etc):
How did you hear about us?
 
 
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27700 Hoover Road, Warren, Michigan 48093
P. (586) 393-8800 F. (586) 393-8810 info@michbusiness.org