• Home
  • Get A Quote
    • Automobile
    • Business & CommercialImage of right arrow
      • Commercial Auto Insurance Quote
      • General Liability Quote Form
      • Workers Compensation Quote
    • Health
    • HomeownersImage of right arrow
      • Homeowners Insurance Quote
      • Homeowner Flood Quote Form
    • LifeImage of right arrow
      • Life Insurance Quote
      • Term Life Insurance Quote
    • Motorcycle
  • Customer Service
    • AutomobileImage of right arrow
      • Request ID Card for Auto Policy
      • Request Declaration and Coverages Page for Auto Policy
      • Send Declaration and Coverages Information to Lien Holder
    • Business & CommercialImage of right arrow
      • Request ID Card for Commercial Auto Policy
      • Request Declaration and Coverages Page for Commercial Auto Policy
      • Request General Liability Certificate of Insurance
    • Financial Services
    • Health
    • HomeownersImage of right arrow
      • Request Declaration and Coverages for Existing Homeowners Insurance Coverage
      • Request Evidence of Insurance
    • MotorcycleImage of right arrow
      • Request ID Card for Motorcycle Policy
      • Request Declaration and Coverages Page for Motorcycle Policy
  • Blog
  • Resources
    • Secure File Area
    • Refer a Friend
    • Important Files
    • Insurance Glossary
  • About Us
    • About S E Benchmark Agency, INC
    • Location Map
    • Employee Directory
    • Customer Testimonials
    • Privacy Policy
  • Contact
    • Contact Us
    • Join Our Newsletter
Call Us (772) 742-2626 ☰ ˟
HomeGet A Quote
AutomobileBusiness & CommercialImage of right arrowCommercial Auto Insurance QuoteGeneral Liability Quote FormWorkers Compensation QuoteHealthHomeownersImage of right arrowHomeowners Insurance QuoteHomeowner Flood Quote FormLifeImage of right arrowLife Insurance QuoteTerm Life Insurance QuoteMotorcycle
Customer Service
AutomobileImage of right arrowRequest ID Card for Auto PolicyRequest Declaration and Coverages Page for Auto PolicySend Declaration and Coverages Information to Lien HolderBusiness & CommercialImage of right arrowRequest ID Card for Commercial Auto PolicyRequest Declaration and Coverages Page for Commercial Auto PolicyRequest General Liability Certificate of InsuranceFinancial ServicesHealthHomeownersImage of right arrowRequest Declaration and Coverages for Existing Homeowners Insurance CoverageRequest Evidence of InsuranceMotorcycleImage of right arrowRequest ID Card for Motorcycle PolicyRequest Declaration and Coverages Page for Motorcycle Policy
BlogResources
Secure File AreaRefer a FriendImportant FilesInsurance Glossary
About Us
About S E Benchmark Agency, INCLocation MapEmployee DirectoryCustomer TestimonialsPrivacy Policy
Contact
Contact UsJoin Our Newsletter
Manage Policy File a Claim
Logo
(772) 742-2626
Icon Icon Icon Icon Icon Icon
Home > Health > Request Declaration and Coverages Page for Existing Health Insurance Coverage
Secured by SSL

Request Declaration and Coverages Page for Existing Health Insurance Coverage


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
Alternate Phone Number
E-Mail Address *
Policy Information
Policy Number *
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Secured by SSL
Insurance Websites Designed and Hosted by Insurance Website Builder
Facebook
Instagram
Google+
Twitter
Get Directions
Contact Us Today
Resources
Products
Customer Service
Payment Options
Newsletter
Gallery
About Us
Refer A Friend
Our Carriers
Blog
Contact Us
Contact us 2138 N US Highway 1
Ft. Pierce, FL 34946

P: 772-742-2626
F: 772-742-1702
E: support@sebenchmark.com
© Copyright. All rights reserved. Powered by Insurance Website Builder.
Facebook