BRM: Information Form

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			Intelligent System Solutions for Group and Individual Insurance

Information Form

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Please fill out the following form so we can understand your business needs. An * indicates a required field.



General Information

* Company Name
Company Address
Company City
Company State	Zip
* Your Name
Your Title
Your Phone
Your Email


Type of Business

Insurer		Commercial Company
TPA		Software Vendor
Reinsurer		Other


Present Products

Group		LTD
Life		Medical
Individual		STD
DI		Dental


Network Environment

Mainframe		Client/Server
DOS		LAN or WAN
Mostly Manual		Dumb Terminal
PC 486 - Pentium		PC Other


Software Interest

Medical Claim Management		Administrative Systems
Disability Claim Management		Life Claim Management
Dental Claim Management


System Status

We are going to build in-house.
We want to buy a system and purchase code.
We want to buy a complete system and support package.
We are surveying product availability.


Installation Needs

6 - 12 Months
12 - 24 Months
24 - 36 Months
Just Exploring


Size of Claim Block

500 - 1000 Claims
1000 - 3000 Claims
3000 - 5000 Claims
5000 or more Claims


Other

Please send additional information.
Please call me to discuss.
We would like a product demo.


Comments


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