UPDATED The Ohio Employer's Health Plan RFP Submission

The Ohio Employer's Health Plan

Request For Proposal
Submitting Broker Agency*
Broker Contact Name*
Employer Name*
Tax ID*
SIC Code*
Employer Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Contact Name*

First NameLast Name
Phone Number*
Email Address:*
Email
Does this group have current coverage?*

YesNo
Is submitting broker the Broker of Record?*

YesNo, this is a prospect
Effective Date*

MonthDayYear
Date
Group Size*

Small 5-50Large 51+
WHAT TO INCLUDE

RFP: Small Group 5-50

1.) FormFire Applications ( Highly Recommended - SSFS Universal App )

OR

Complete Benefit Eligible Dependent Level Census including enrollments, if applicable

2.) Current / most recent renewal plan summary and rates, if applicable

Census Template
1.) Complete Benefit Eligible Dependent Level Census*

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2.) Current / Most Recent Renewal Plan Summary and Rate *

Cancelof
WHAT TO INCLUDE

RFP: Large Group 51+

1.) Complete Benefit Eligible Dependent Level Census including enrollment tier and plan option selected

2.) Current / most recent renewal plan summary and rates, if applicable

3.) Two (2) years claims experience (Employee counts and Claims by Month)

Census Template
1.) Complete Benefit Eligible Dependent Level Census*

Cancelof
2.) Current / Most Recent Renewal Plan Summary and Rate *

Cancelof
3.) Two (2) Years Claims Experience (Employee Counts and Claims by Month*

Cancelof
Should be Empty: