PMD Request for Proposal

Instructions

1. Complete this form. (You can request up to 3 plan designs per submission)

2. Attach Current Census. (Census must include Employee Name, Sex, DOB and Coverage Tier. Dependent information is NOT needed.)

Todays Date*

Date

Quote Effective Date*

Date

Agency Name*

Agent Name*

First NameLast Name

Agent Email*

example@example.com

Broker Name on Proposal*

Commission Type*

Select One

Commission Amount*

Ex. 20% or $15 PEPM

Group Name*

Situs State*

Nature of Business

SIC Code

Required for Zurich Quotes ONLY

Eligible Lives*

Select TPA*

S&S (Magna)Loomis (FSL)ACI (Zurich)

Plans Requested

Maximum Plans per Submission is 3. If additional plans are needed, please submit a separate quote.

Plan 1 - Deductible

Plan 1 - Family Deductible

Plan 1 - Coinsurance %

paid by the Insured

Plan 1 - Max Benefit

Plan 1 - Brand & Generic Outpatient Rx Rider

Yes (Shared Deductible Plan)No

Plan 1 - Outpatient Physician Office Visit Rider

YesNo

Plan 1 - Office Visit Copays

YesNo

Plan 1 - Office Visit Copays Start:

Before GAP DeductibleAfter GAP Deductible

Plan 1 - PCP Copay

Plan 1 - SPC Copay

Plan 1 - UC Copay

Plan 1 - ER Copay

Plan 1 - Rx Benefit

YesNo

Plan 1 - Rx Deductible

Must be a minimum of $4,000 deductible to be Shared with Medical.

Plan 1 - Rx Benefit Starts:

Before GAP DeductibleAfter GAP Deductible

Plan 1 - Rx Copays

YesNo

Plan 1 - Tier 1 Copay

Plan 1 - Tier 2 Copay

Plan 1 - Tier 3 Copay

Plan 1 - Specialty Copay*

Additional Premium will be added for Specialty

Request for GAP Proposal

AGENCY / AGENT INFORMATION

GROUP INFORMATION

PLANS DESIGNS

PLAN 1

PLAN 1 RIDERS

PLAN 2

PLAN 2 RIDERS

PLAN 3

PLAN 3 RIDERS