Exit this survey

ORDER FORM - 2019 UBA Health Plan Survey EXECUTIVE SUMMARY

Thank you for choosing to order the 2019 UBA Health Plan Survey Executive Summary. UBA will be accepting orders through October 1, 2019. If you are ordering co-branded brochures, you will receive a proof the first week of October.
  • Print orders will begin shipping mid-October. Pricing will be based on the combined Partner orders to get the lowest possible cost per piece.
  • Brochures will cost $1.25 to $2.00 per brochure + shipping depending on the total number of print orders. The higher the print quantity or number of orders, the lower the price per brochure.

Question Title

* 1. Name of the Partner Firm submitting orders

Question Title

* 2. Email Address: (contact person for questions)

Question Title

* 3. Name: (person who is ordering the brochures)

Question Title

* 4. Address: (where the brochures will be delivered)

Question Title

* 5. Address 2:

Question Title

* 6. City:

Question Title

* 7. State:

Question Title

* 8. Zip Code:

Question Title

* 9. Company Phone:

Question Title

* 10. Website URL:

Question Title

* 11. I would like to order Standard UBA-branded brochures (does not include my Firm logo or my contact information)

Question Title

* 12. I would like to order Co-branded brochures (includes my Firm logo on the front cover and my Firm logo and address on the back cover

Question Title

* 13. CO-BRANDED BROCHURES ONLY - If the address and contact information above is different than the address and contact information that you would like to appear on the back of the printed co-branded brochure, please type in the address and contact information below:

Question Title

* 14. CO-BRANDED BROCHURES ONLY - If you would like to order brochures for MORE THAN ONE OFFICE LOCATION, please type in the additional address and order quantity below:

( Privacy & Cookie Notice

T