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Employee Benefits Proposal Request
Company Name
Zip Code
Contact Name
Contact Phone
Fax
Do you have a current plan?
Yes
No
Next renewal date
Health Plan Options Requested
Type
-- select --
HMO
POS
PPO
Co-Pay
-- select --
$20
$25
$30
Deductible
-- select --
$500
$1,000
$2,500
Co-Insurance (if applicable)
-- select --
80/20
70/30
60/40
50/50
Hosptial Co-Pay (if applicable)
-- select --
$250
$300
$500
$750
Note, 5 night max per illness, then cover 100%
Stop Loss
-- select --
$5,000
$10,000
Employee Name
Sex
Birth Date
Status
Job Title
Home Zip
1
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
2
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
3
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
4
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
5
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
6
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
7
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
8
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
9
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
10
M
F
Employee only
Employee & Spouse
Employee & Child(ren)
Family
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