Proposal Request
Use for group proposals-
About the Client:
Company Name
*
What state is the group domiciled?
*
Number of Employees
*
Full-Time Benefit Eligible Employees
What plans are available to the group?
HDHP
Traditional PPO/POS
HMO
HDHP w/HSA
Other
Employee Breakdown
Rows
18-35
36-48
49-62
63-66
67+
Number of Employees
Enrollment Elections
Rows
HMO
Traditional PPO/POS
HDHP
HDHP w/HSA
Other
Number of Enrollments by Employee
Enrollment Overview
Rows
EE Only
EE and ES
EE and Children
Family
Number of Enrollments by Type
Spouse/Domestic Partner Insights
Rows
18-35
36-48
49-62
63-66
67+
Number of Spouse/Domestic Partners Enrolled
Spouse/Domestic Partner Insights
Rows
HMO
Traditional PPO/POS
HDHP
HDHP w/HSA
Other
Number of Enrollments by Spouse/Domestic Partners
Type of Benefits and/or Plans Available to Employees:
*
Allocated Benefit Costs per Employee by Plan:
*
Targeted Effective Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Objective for Proposal:
Company Background:
What is your relationship with the client or any other information that will help us help you win the deal?
Help us understand the value add you are offering
Any relevant files to use for ROI determination in proposal:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please add the following to the proposal:
ROI calculations
Reporting Samples
Break-even Analysis
Other
Proposal Contact Form
Who should we contact with the final proposal and/or any questions
Name of Consultant Requesting Proposal
*
First Name
Last Name
Preferred Contact Method
*
Please Select
Email
Phone
Text
Mobile Number
*
Format: (000) 000-0000.
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date Proposal is Needed:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: