HHP - Quote Information > Group Proposal Request (51 + Employees)

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Quote Information
To request a Group Proposal please fill out the following form:
Group Proposal Request

Underwriting Guidelines

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)

Hometown Health | 830 Harvard Way | Reno, Nevada 89502 | 775-982-3000