RFP Submission

Submit new RFP details for review and routing.

Requested Effective Date

Business Information:

Company Legal Name

Physical Address

City

State

Select

Zip

Main Contact Person (C-Level, HR Manager, or Decision Maker)*

Email Address*

Telephone*

Phone

Industry

Select or enter value

SIC Code

# of Pay Periods

12 - Monthly

24 - Semi-Monthly

26 - Bi-Weekly

52 - Weekly

Current Plan Information:

Current Medical Carrier

# of Enrolled EEs

Current Funding Arrangement

N/A

Fully-Insured

Level Funded

Self Funded

Administrative Services Only (ASO)

# of Health Plans Offered*

N/A

1

2

3

4

Plan Name (Plan 1)

Current Rates (Plan 1)

Add Premium Amounts to Composite Rates

Plan Name (Plan 2)

Current Rates (Plan 2)

Plan Name (Plan 3)

Current Rates (Plan 3)

Plan Name (Plan 4)

Current Rates (Plan 4)

Funding Arrangement Requested

Level Funded

Self Funded

Administrative Services Only (ASO)

Not Sure

Plan Design Requested

PPO

CoPay Plan

HDHP

Benefit Consultant*

Select or enter value

Submitted By*

Select or enter value

File(s) Upload Section

Claim and Diagnosis Reports

Large Claim Reports with Diagnosis

> 100: 3 years of data (in 12-month increments)

< 100 with no experience: Individual Medical Questionnaires

Large Claimant Report - Claims in Excess of $10,000

Catastrophic Diagnosis and Prognosis

MERP - HRA Claims

Paid Claims and Monthly Enrollment Statistics

State Mandated Claims Report

Enrollment and Premium Data

SBC(s) for each plan

Plan Documents

Published Renewal

Three Years of Historical Rates

FIle Upload*

Upload the Checked Boxes From the File(s) Upload Section Here

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