Name of Prospect Location Zip Code Nature of Business Are you currently the Broker? Yes No Your Name* Your Phone* Does your prospect currently have Vision coverage? Yes No If Yes, fill out this sectionWhat is/are the current plan(s)?Please include benefit summaries for prepaid and idemnityCurrent 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.Employees InformationTotal 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? Coverage InformationRequested 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 reddit ask women
