This is BNMs insurance product to the cannabis industry.

1. SAVE 15%-30%
MAJOR MEDICAL
Now Insuring Properly Licensed MRBs
Improve Your Bottom
Line With Savings on
Health Insurance
____
Leverage Our
Purchasing Power
and Save
____
Why Pay More for
Benefits if You are a
MRB?
____
Submit This Form
and We Will Follow
Up With You to
Discuss Next Steps
____
AMERICAN BENEFITS
EXCHANGE
9600 Great Hills Tr. STE
100E
Austin, TX 78759
www.thinkabx.com

2. MRB Company Profile For Health Insurance Quote
Employer Data
Full Legal Business Name:
Type of Business: C Corp S Corp Sole Proprietorship LLC Non-Profit Other
Nature of Business: Agriculture Store Front Processing Transport Other
Business Address: City: State: Zip:
Address on tax returns
(if different):
City: State: Zip:
Business Owner Name: Phone: Email:
Company Contact Name: Phone: Email:
Federal Tax ID #: Date Business Started: Total Employees:
Names & Address of Additional Locations / Subsidiaries / Affiliates:
Name: Address:
Name: Address:
Name: Address:
Additional Details
Please briefly describe the company’s business activities
The Business Owner(s) goal is to (check all that apply):
 Provide best coverage for all employees  Provide best coverage for management  Provide 2 different plans based on class
Do you currently offer Health Insurance?  Yes  No If “No”, please leave comments on any desired budget or plan design.
If “Yes” What type of Plan?  Minimal Essential Coverage / Minimum Value  High Deductible  Comprehensive
Name of Insurance Carrier: Renewal Date:
Employer Contr. %: Number of Employees Participating: Annual Deductible: Individual/Family: $ /
Monthly Rates: EE: EC: Comments:
ES: EF:
Consultant Information
Consultant Name:
Street: City: State: Zip:
Phone #: Fax #: Email:
I have explained to the Employer that this confidential information will not be shared or disclosed to any other third party except the employees/associates
of BNM Partners, through its insurance agency affiliate American Benefits Exchange (ABX), MAHCA Health Captive who have a need to know for the
purpose of providing Health Insurance. This policy will also govern all communications between the parties, including fax, email and secure online
uploads. I have further explained that as a consultant of American Benefits Exchange, and representative of BNM Partners, I am not a tax professional
and do not give financial, legal, or tax advice. I have further advised client they should consult their tax advisor and/or attorney as needed.
Signature of Consultant: Date:
Submit to BNMpartners@thinkabx.com
Submit Form