Organization Name 

Industry Type 

School District  
Other (please describe)  

Address 

City 

State 

Zip 

County 

Telephone 

Fax # 

Contact Name 

Job Title 

Contact E-Mail Address 

Total Number of Employees

(including those waiving coverage, on COBRA or retired)

Please send a proposal for

Medical

PPO   HMO   Self-Funded   HSA

Flexible Spending Plans

Dental

Board Paid Life

Long Term Disability

403(b) Compliance Services

If requesting medical proposal, please complete current health plan information:

Current Carrier

Number of Covered Employees

  (including those on COBRA or retired)

Deductible  

Monthly Premium  

  (per employee)

Coinsurance  

Copays  

Rx Benefit  

Employee Census Data

You can send your census by:

• File Upload - Upload a file with your census in the box below. (Please include the fields shown below.)
  

      Upload File    

• Fax - Download the Request for Proposal and fax to 816-968-0557.

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