Fillable Printable Request For Proposal Form
Fillable Printable Request For Proposal Form
Request For Proposal Form
REQUEST FOR PROPOSAL FORM
SMALL GROUPS (1-100 Full-time Equivalent Employees)
Effective Starting For January 1, 2016 Coverage Dates
Broker Information Business/Group Information
Broker Name Company Name
Agency Name DBA
Address City Zip
City Zip Effective Date Requested
Phone Nature of Business
Fax Current Carrier(s)
Email Address Has company filed bankruptcy in last 5 yrs? Yes No
Broker License Number # of Eligible EE's* # of enrolled EE's
Commission Requested %
Broker Of Record? Yes No
Reason for shopping: Employer Contribution For Employee: % or $
Unhappy w/rates Unhappy w/benefits Employer Contribution For Dependents: % or $
Market Check Other
How did you hear about us? Is the group interested in Dental Insurance?
Yes No
Additional Comments:
Please return completed form with census and current carrier/renewal rates attached to: [email protected]
*Eligible employees are permanent, active, full-time employees working a minimum of 30 hours per
week. The following classifications are NOT eligible: employees working less than 30 hours per week,
leased employees, seasonal employees, 1099, union, board members, retirees, COBRA participants
or surviving spouses.
REQUEST FOR PROPOSAL FORM
LARGE GROUPS (101+ Full Time Equivalent Employees)
Effective Starting For January 1, 2016 Coverage Dates
Broker Information Business/Group Information
Broker Name Company Name
Agency Name DBA
Address City Zip
City & State Zip Effective Date Requested
Phone Nature of Business
Fax Current Carrier(s)
Email Address
Yes No
Broker License Number
# of enrolled EE's
Commission Requested
%
Broker Of Record?
Yes No
Yes
Reason for shopping: Employer Contribution For Employee: % or $
Unhappy w/rates Unhappy w/benefits Employer Contribution For Dependents: % or $
Market Check Other
Any large claims over $25,000 in the last 12 months?
Yes No
How did you hear about us ? Is the group interested in Dental Insurance?
Any non-active employees for a reason other than vacation?
Yes No
Yes No
Any Cal-Cobra/Cobra beneficiaries?
Yes No
If so, how many?
Please return completed form with census and current/renewal carrier rates attached to: [email protected]
Does the group currently offer cross-border
health care coverage?
# of Full time
Eligible EE's*
*Eligible employees are permanent, active, full-time employees working a minimum of 30 hours
per week. The following classifications are NOT eligible: employees working less than 30 hours
per week, leased employees, seasonal employees, 1099, union, board members, retirees,
COBRA participants or surviving spouses.
Any Special
Considerations?
If Group has less than 101 EEs that work full time, but still qualifies as a large group
with 101+ FTE, check Yes in block. Broker will need to provide a signed attestation
when the master application is submitted certifying that large group size FTE
calculation was properly performed.
