NABIP | UBA Eligibility

Agency Name: *

Business Address: *

City: *

State: *

Zip Code: *

Agency Contact: *

Phone: *

Email: *

Other agency names your company may be doing business as (dba):

States where your agency has offices (Please list all that apply): *

Total number of agency employees: *

Eligible Agency Members (EAM): Employees who work with your clients on employee benefits, individual health insurance, Medicare or other health related products, including but not limited to producers, account managers, and compliance professionals.

Number of employees who are EAMs *

Number of current NAHU members (if applicable):

Upload list of EAM's

Are You A Robot? *

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UBA Agency Membership Eligibility Form