Request For Proposal

Name of Prospect

Location

Zip Code

Nature of Business

Are you currently the Broker?

Yes

Your Name(Required)

Your Phone(Required)

Does your prospect currently have Vision coverage?

Yes

What is/are the current plan(s)?

Please include benefit summaries for prepaid and idemnity

Current Rates:

Please include rates for single, couple, and family for prepaid and idemnity plans.

Renewal Rates:

Please include rates for single, couple, and family for prepaid and idemnity plans.

Total Number of Employees

Total Number of Eligible Employees

Total Number of Participating Employees (Please include census)

What Percentage of the Employee Premium is the Employer Contributing?

What percentage of the Dependent Premiums is the Employer Contributing?

Requested Coverage

Voluntary

Employer Paid

Requested Benefit Design; Deductible (if any) for Prepaid Plans:

Requested Benefit Design; Deductible (if any) for Indemnity Plans:

Requested Effective Date

Broker Name

Broker Fax or Email

Request for Proposal