HOW TO GET MORE INFORMATION

Request information to be mailed to you. (Refer to the form below)

	2011 SAMBA Health Benefit Plan		Personal Accident Insurance
	Term Life Insurance		Dental & Vision Plan
	Disability Income Protection

NOTE: Term Life Insurance and Disability Income Protection plans are only available to active employees.

Provide your contact information in the form below.

REQUEST INFORMATION FORM

*First Name:

*Last Name:

Phone:
- -

*Address:

*Email:

*City:

*State:

*Zip Code:

Are you: Active Retired Agency:

* - You must complete all fields marked with a red asterisk (*)

For questions or comments about the SAMBA Health Benefit Plan, send us an email at: HealthPlan@sambaplans.com
For questions or comments about any other SAMBA plan, send us an email at: Insurance@sambaplans.com
Call SAMBA's Customer Service representatives at (800) 638-6589, Monday through Friday, from 8:00 a.m. until 5:00 p.m., EST.