2026-27 The Ohio Employer's Health Plan BROKER RFP Submission

The Ohio Employer's Health Plan

Request For Proposal
Submitting Broker Agency
Broker Contact Name
Broker Contact Email
example@example.com
Employer Name
Tax ID
SIC Code
Employer Primary Address

Street Address

CityState

Zip Code
Employer Contact Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email Address:
Email
Is submitting broker the Broker of Record?
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does this group have current coverage?
Group Size (Number of People Enrolled)
WHAT TO INCLUDE

RFP: Small Group 5-50

1.) Member Level Census, including all enrolling employees and dependants.

-- Please include home zip codes, enrollment tiers, and label spouses/children.

2.) Current or most recent renewal.

-- If quoting off cycle, please include a carrier billing statement and SBC.

3A.) Health Apps / Medical Questionnaires (IMQs) *Optional, but recommended!*

-- If using FormFire, please send "Universal Applications" - "SSFS 10-50 EE Enroll"

3B.) SARA Employer Questionnaire**

** THIS FORM IS ONLY REQUIRED IF YOU DO NOT HAVE APPS AND FOR GROUPS WITH 10+ ENROLLED. (See below to download a copy.)
1.) Member Level Census

Cancelof
2.) Renewal and/or Billing Statement with SBC

Cancelof
3.) Medical Apps / IMQs OR 4.) SARA Questionnaire

Cancelof
4.) SARA Employer Questionnaire**
WHAT TO INCLUDE

RFP: Large Group 51+

1.) Member Level Census, including all enrolling employees and dependants.

-- Please include home zip codes, enrollment tiers, and label spouses/children.

2.) Current or most recent renewal.

-- If quoting off cycle, please include a carrier billing statement and SBC.

3A.) Health Apps / Medical Questionnaires (IMQs) *Optional, but recommended!*

-- If using FormFire, please send "Universal Applications" - "SSFS 10-50 EE Enroll"

3B.) SARA Employer Questionnaire**

** Required for groups under 100 with NO IMQs. (See below to download a copy.)

4.) If currently level-funded or self-funded: Two (2) years claims experience.

-- Employee Counts and Claims by Month
1.) Member Level Census

Cancelof
2.) Renewal and/or Billing Statement with SBC

Cancelof
3.) Health Apps / IMQs or SARA Questionnaire

Cancelof
4.) Two Years Claims Experience

Cancelof
SARA Employer Questionnaire**
Should be Empty: