Request for Proposal/Quote

Company Name (Plan Sponsor) * Required

# of eligible employees

Broker Involved

Yes

NO - Direct to Employer

Broker of Record (to be added to front of proposal)

Industry

SIC Code

Situs Business Address HQ * Required

Date Quote Submitted

Plan Anniversary Date * Required

Quote Deadline

Current Active Plans

Major Med (No MEC)

MEC Only No MV

MEC & MV

No Benefits

Attach Current Plan (Summary and SPD)

Please indicate if the rates are renewal or old

Employer Contribution

75% to 100% Emp Only

50% to 75% Emp Only

Under 50%

Voluntary

Requested Plans

MEC Only (No Ancillary Options)

MEC Plus (Indemntiy or Copay plans)

MEC Plus MVP (Census Included)

Include Voluntary Dental and/or Vision

Include Separate Hospital Indemnity Buy-Up

GAP Plan

Other (See Below)

Other Plan Type

Commissions

Standard Broker Fee

GA Override

Additional Broker Fees (see below)

Additional Supplemental Fee (Max $10)

NOTE: A competitor may quote without the supplemental fee

$

Census Attached

Please use editable format (EXCEL) with AGE/Gender/ZIP