Use this form to request an underwritten quote for your group.
REQUEST UNDERWRITTEN QUOTE
Contact Information
Contact Name:
*
Email Address:
Phone Number:
*
General Information
Date Rate Needed:
*
Company:
City:
County:
State:
Broker Firm:
Broker Name:
# EEs:
Effective Date:
*
Renewal Date:
*
Current Coverage
Census Info
Current Rates
Renewal Rates
EE:
EE:
EE:
EE + Sp:
EE + Sp:
EE + Sp:
EE + Ch:
EE + Ch:
EE + Ch:
EE + Chn:
EE + Chn:
EE + Chn:
Family:
Family:
Family:
Waived:
Composite:
Composite:
Cobra:
ASO Admin Fee:
ASO Admin Fee:
Total Enrolled:
Total Members:
Plan Design
In-Network
Out-of-Network
Preventative:
Basic:
Major:
Contract Max:
Ortho:
Ortho Max:
Deductible:
Copay:
Current Carrier:
Yrs with Carrier:
Current ER Contribn:
Underwriting Instructions
Yes
No
Employer Contribution:
Out of State Employees:
Rate Guarantee:
Commission Request:
Cap:
Special List of
Covered Services:
Special Instructions/Notes:
Plan Designs to Quote
ASO Plan:
Yes
No
Funding Rates:
Yes
No
Admin Fee:
Fully-Insured:
Yes
No
Supplemental Plan(s):
Yes
No
Superior Vision:
Yes
No
Plan A
Plan B
Plan C
Plan D
check one:
check one:
check one:
check one:
Open Access
Open Access
Open Access
Open Access
Network Only
Network Only
Network Only
Network Only
Point of Service
Point of Service
Point of Service
Point of Service
In
Out
In
Out
In
Out
In
Out
Preventive:
Basic:
Major:
Contract Max:
Ortho:
Ortho Max:
Deductible:
Copay (Amount):
For Direct Quotes:
Option 1
Option 2
Option 3
Yes No
Yes No
Yes No
Funding Rates
Funding Rates
Funding Rates
Network
Network
Network
Admin Fee
Admin Fee
Admin Fee
of first
of first
of first
of next
of next
of next
of next
of next
of next
Contract Max:
Ortho:
of first
of first
of first
Ortho Max: