Fillable Printable Request For Proposal Form # 1001 1-22-201
Fillable Printable Request For Proposal Form # 1001 1-22-201
Request For Proposal Form # 1001 1-22-201
Request for Proposal
Essenal Bronze
Plus Program
HSA
Compable GAP
Major Medical
GAP
Limited Medical Dental
E‐MEC Vision
Secon 125
MEC
Name of Prospect: Proposed Effecve
Date:
Prospect’s Legal Address: Number Eligible
Employees:
Industry (please be specific):
List Other Locaons Including Zip Codes:
Corporaon Partnership Associaon MEWA
Trust Union PEO Sole Proprietorship
Other (Specify)
CENSUS REQUIRED FOR GAP & MAJOR MEDICAL QUOTES ‐ Please aach a census including age (or date of birth),
Gender, Zip Code and current Medical er.
Writing Producer/Who commissions will be payable to: Phone:
Fax:
Email:
Name of Group Representave:
Included a copy of the current plan design: Yes No
Please list current and renewal rates:
What employer contribuons are ancipated per employee per month? (please circle one)
0% 25 % 50% 100 % Not sure yet
Please describe any other medical benefits the employer makes available to this group of employees or that the employer may
be interested in:
Addional Informaon:
Plans requested:
Producers Signature: Date:
Submit Proposal requests to:
OpMed’s Proposal Department
Proposal@opmedhealth.com
Or Fax to: 215‐968‐6301
Form #1001
Tax ID Number:
