Quote Information > Group Proposal Request

Basic Group Information:
Name of Group:
Contact Person:
Group Address (physical):
City:
State:
Zip:
Phone #:
Fax #:
E-Mail:
SIC code or complete description of what the company does:
Years in business:
Requested Effective Date of Coverage:
Known Medical Conditions of Group:
Total # of Employees:
Total # of Eligible Employees:
Total # of COBRA=s active:
Total # of COBRA=s pending:
Employer Contribution % for Employee:
Employer contribution % for Dependents:

Current Carrier Information (If Known):
Name of Current Carrier:
Number of years with Current Carrier:
Current Benefit Design:
Current Rates:
Renewal Rates:

Requested Plans to be Proposed:
Rate Tier Structure: 4 Tier 5 Tier
HMO: Yes No
PPO: Yes No
Copays: $5 $10 $15 $20
Coinsurance: 80/20 90/10
Deductibles:$100 $250 $500 $1,000
HMO Rx Copay: $5 / $15 $8 / $24 $10/ $30
PPO Rx Copay: $5/$15/40% $8/$24/40% $10/$30/40%
Dental: Yes No
Vision: Yes No

Census Information

Gender	Age	Spouse	Children
Male	45	Yes	3   (Example)
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo
MaleFemale		YesNo