VA - Health Insurance Proposal Request Form

Health Insurance Proposal Request Form

First Name:		City
Last Name:		State
Company:		Zip
Street Address 1:		Phone#:
Street Address 2:		Fax#:
		E-Mail:


Group Name:
Nature of Business:
County:		State:		Zip Code:
Requested Effective Date:
Do the employees contribute towards the cost of health insurance ?			Number of employees in Company:
Number of employees participating in health plan:			Number of employees covered by another health plan:
Does this employer sponsor more than one health plan ?
Census:
Employee:			EE & Spouse:
EE & 1 Child:			EE & Children:
Full Family:
Location of Employees:	Suffolk, Nassau, Queens			NY State
	Tri-State			Other

If other (please give City,
State and Zip Code of employees):

Type of Plans to be Quoted:	HMO	POS	PPO	INDEMNITY
Prescription Drug Card: Generic:	$5	$10	$15	$20
Brand:	$5	$10	$15	$20
Non-Formulary:	$25	$30	$35	$50
Deductible:		$50	$75	$100

UCR Level:	70% 80% 90%
Office Co-payment:
Hospital Co-payment:
Current Plan: Carrier, Copay, Deductible, Co-Insurance, Prescription Drug Card, Hospital Co-Pay

Current Rates:
Single: EE/SP: EE/1 Child:
EE/Children: Full Families:
Renewal Date:

What is the client trying to accomplish:	Does not like current carrier
	Lower Cost
	Improve Doctor Network
	Improve Benefits

Please add any suggestions or comments which might be helpful.

Do you wish your proposal sent to you by: Mail Fax E-Mail

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