Greater Miami Chamber of Commerce Survey

1. Group Name: *This question is required.

2. Primary Contact Name: *This question is required.

3. Phone Number: *This question is required.

4. Email: *This question is required.

5. Preferred Method of Contact: *This question is required.

6. Does your company have a current health plan? *This question is required.

7. If yes, name of insurance company:

8. Number of employees: *This question is required. This question requires a valid number format.

9. Do you have a group benefits agent? *This question is required.