Request for Proposal
Section 1: Company Information
Company Name:
*
Number of Full-Time and Part-Time Employees:
*
Number of Full-Time Active Employees:
*
Working at least 30 hours per week
Number of Eligible Employees:
*
Number of Enrolling Employees:
*
Number of Employees Covered under or in election period of COBRA:
Number of Employees in their Waiting Period:
Waiting Period for New Hires
1st of the Month after 30 Days
1st of the Month after 60 Days
1st of the Month after Date of Hire
Date of Hire
Nature of Company Business:
SIC Code:
*
Tax ID#:
Date Business Started:
-
Month
-
Day
Year
Date
Company Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Multiple Locations:
Yes
No
If Yes, Provide Zip Codes:
Name of Current Health Insurance Carrier:
How long with the carrier:
# of Years
Plan Renewal Date:
*
-
Month
-
Day
Year
Date
Section 2: Current / Renewal Rates
Current Benefit Design 1:
Ex. $2000 Deductible / $6000 Max Out-of-Pocket / 80% Coinsurance / PPO
Current Rates
Monthly Rate
EE
ES
EC
FAM
Renewal Benefit Design 1:
Ex. $2000 Deductible / $6000 Max Out-of-Pocket / 80% Coinsurance / PPO
Renewal Rates
Monthly Rate
EE
ES
EC
FAM
Current Benefit Design 2:
Ex. $2000 Deductible / $6000 Max Out-of-Pocket / 80% Coinsurance / PPO
Current Rates
Monthly Rate
EE
ES
EC
FAM
Renewal Benefit Design 2:
Ex. $2000 Deductible / $6000 Max Out-of-Pocket / 80% Coinsurance / PPO
Renewal Rates
Monthly Rate
EE
ES
EC
FAM
Section 3: Agency / Agent Information
Agency Name:
Broker Name:
*
First Name
Last Name
Broker E-Mail
*
example@example.com
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