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Group Proposal Request Form

 

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Group Proposal Request form
 
Today’s Date Requested Effective Date
You’re Company’s Name: Nature of Business
You’re Companies Address: TX:
Your Present Coverage with: Your Company’s SIC (Standard Industry code):
 
Current Medical Rates: EE $ EC $ ES $ FA $
Renewal Rates: EE $ EC $ ES $ FA $
 
No. Of Employees working: No. Of Eligible (Non-Seasonal Full-time) Employees:
Workers Comp. Coverage:  
No. Of Pregnancies: Due:
 
Employer Insurance Contribution For:
Employee: $ Dependants: $
 
ANY CLAIMS IN THE PAST 12 MONTHS OR FORSEEABLE FUTURE OVER $7000?
ANY MEDICAL CONDITIONS (example: Aids, Cancer, Diabetes, Heart, Kidney, Lungs)?
(Do not use any names)
Note: Use ',' to seperate the claims and medical conditions
 
Are any of the Insured’s or Dependents Currently on Cobra of State continuation?
Who?
Note: Use ',' to seperate the names
Do You Want to See?


 
What Coinsurance do you want to see?


 
What Maximum Out of Pocket after Deductible would you like quoted? (In Network / Out Network)


 
What Deductibles would you like to see quoted: (In the Network / Out of the Network)




 
What Prescription Copays would you like to see quoted: Generic / Brand / Non-Formulary



 
What Dr Visit Copay’s would you like quoted; Primary Visit Copay / Specialist Visit Copay






Employee Census Data
 
Enter your Employee Details and click add Employee
Employee Name Gender
Date Of Birth(MM/DD/YYYY) Type of Coverage
Number of Kids Occupational Class
Full-time / Part-time Residence Zip Code
 
Questions? Contact Us today!

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Local: (512) 401-2100
Fax: (888) 395-7084
P.O. Box 2272
Round Rock, TX 78680