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Confidentiality Agreement

We protect the confidentiality of our members’ personal financial and health information as required by law and our internal policies and procedures. This client Confidentiality Statement explains your rights, our legal duties and privacy practices.

Your Financial Information

In order to conduct health insurance/benefits activities, we collect and use several different types of financial information. This includes information that you provide directly to us on applications or other such forms (census), such as your name, address, occupation, salary, age, and information about dependents. We also may accumulate information about your transactions with insurance companies such as policy coverage, premiums, claims data, and premium payment history.

We use physical, electronic, and procedural safeguards to protect your confidential information. We make it available only to our employees or others who need it to service or maintain your policy, to conduct insurance transactions and functions or for other legally permitted or required purposes.

For payment: We may use or disclose information about you in managing your account or benefits. For example, we maintain information about your premium and coverage election. We may also provide information to a doctor’s office to confirm your eligibility for benefits or the coverage provided under your certificate.

For Operations: With your written approval via group level risk assessment or broker of record letter, we may use or disclose health information on a group level basis about your account for the purpose of insurance/benefits transactions and operations. Without this information, we would be unable to accurately and effectively market your account to the various financial markets needed to meet your objectives.

Consistent with the above, all current and future employees and business associates are required to sign and uphold our confidentiality agreement. Should you have any questions concerning this agreement or how we protect your private information, please do not hesitate to contact our office.

NC Residents Only

If you are interested in our insurance options, please complete and submit this form.

First Name:
Last Name:
Zip:
Phone:
Email:

ALL Dates of Birth MUST be entered in this format: mm/dd/yyyy

Date of Birth:
Gender: --None-- Female Male

Spouse Date of Birth:
#Children: --None-- 0 1 2 3 4 5 6 7 8 9

Dependent 1 DOB:
Dependent 1 Gender: --None-- Female Male

Dependent 2 DOB:
Dependent 2 Gender: --None-- Female Male

Dependent 3 DOB:
Dependent 3 Gender: --None-- Female Male

Dependent 4 DOB:
Dependent 4 Gender: --None-- Female Male

Dependent 5 DOB:
Dependent 5 Gender: --None-- Female Male

Products:

Health Insurance:

Blue Advantage

Blue Advantage Saver

Blue Options HSA


Medicare:

Medicare Supplemental

Medicare Advantage

Additional Products:

Dental Insurance

Life Insurance

Individual Disability Income

Annuity Planning

Long Term Care

ALL Dates of Birth MUST be entered in this format: mm/dd/yyyy

IBD Insurance Services, Inc.
3733 National Drive, Suite 232, Raleigh, NC 27612
Phone: 919 510-5980
FAX: 919 510-8876
http://www.ibdinsurance.com