Benservco Plan Services ~ Retirement Plan Administrators

Client Registration Form

Register your profile information and create and client user account. This will give you access to Benservco's
"Client Control Panel" where you can edit your registration information and gain access to specialized features.

All registration information is keep strictly confidential > click here to review our privacy policy.

During the registration process, you can request a quote on a healthcare coverage plan, or you can request a quote
anytime after your have registered.

* Denotes a required field.

Account

* UserName:
* Password:
* Confirm Password:

Registration Type

* Registration Type:
* Quote Type:

Your Information

* First Name:
* Last Name:
Address 1:
Address 2:
City, State, Zip:
* Phone: - -
Fax: - -
* Email: (your email address will be used for email verification)

Request a Quote for a Business/Employer

Send Quote : Presentation Choice :

Business/Employer Information

Company Name:
Type of coverage desired:
Number of Employees:

Display Detailed Census Form: Click here to open census form and list all employees to be covered under the plan

Do you have Existing Coverage? Type of coverage:
Current Insurance Carrier:

Other Comments:

Please note that you will be sent a system generated email verifying your registration. The email will contain your account user ID and password login information. Pleases be sure to save it in a secure location. In the event you do not receive the verification email within 24 hours, please contact us.