Renewal rates:-

Workers comp coverage:-

YesNo

Employer insurance Contribution For:-

Any claims in the past 12 months or forseeable future over $7000?:-

YesNo

Any medical conditions (Example: Aids, Cancer, Diabetes, Heart, Kidney, Lungs)?:-

YesNo

Are any of the insured’s or dependents currently on cobra of state continuation?:-

YesNo

Do you want to see?:-

HMO plansPPO plansDual OptionsBuy-up Options

What coinsurance do you want to see?:-

90%/60%80%/50%70%/50%50%/50%

What maximum Out of pocket after deductible would you like quoted? (In Network / Out Network):-

$1,000 / $2,000$2,000 / $4,000$3,000 / $6,000$4,000 / $8,000

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

$0/$500$0/$1000$250/$500$500/1000$1,000/$2,000$2,000/$3,000

What prescription copays would you like to see quoted: Generic / Brand / Non-Formulary:-

$10/$15/$30$10/$20/$40$10/$25/$50$10/$30/$55Rx Deductible $

What Dr visit copay’s would you like quoted; Primary Visit Copay / Specialist Visit Copay:-

$10 / $20$10 / $30$15 / $30$20 / $40$20 / $50Or No copays

Enter your employee details:-

Gender:-

MaleFemale