Employee Benefit RFP PDF

Sunday, December 8, 2024

Employee Benefit RFP Form

Date

Due Date

Requested Effective Date

Group Name

Cras non velit nec nisi vulputate nonummy. Maecenas tincidunt lacus at velit.

SIC Code/Type of Business

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Group Address

0266 Old Gate Drive, 954 Northfield Alley

Birmingham, Alabama, 35236

United States

Years in Business

Tax ID Number

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# of Eligible Employees

Eligible employees must work # of hrs/wk

Wait period for new hires

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Are There Existing Benefits?

Option 1

Please check all products to be proposed and fill out Sections indicated: (select all that apply)

Option 1

*Complete excel census required for all Life/STD/LTD Products

Dental

Employer Contribution: (If Contributory Please Add Your Contribution in notes)

Option 1

Annual Maximum: (if other please add to notes section)

Option 1

Indemnity Benefit?

If so how much? (

if other please ad

d to notes section

)

Optio

n 1

Deductible: (if other please add to notes section)

Option 1

Endo and Perio Services?

Option 1

Deductible: (if other please add to notes section)

Option 1

Previous Carrier Name:

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Notes: ( please explain all answers marked other below of contribution amounts)

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Vision

Employer Contribution: (If Contributory please add your $ amount per employee? In notes)

Option 1

Frequency of Exam, Lenses, Frames (in mos.): (if other please add to notes section)

Option 1

Material Allowance (Frames or contacts): (if other please add to notes section)

Option 1

Copays (Exam/Material): (if other please add to notes section)

Option 1

Plan Type:

Option 1

Carrier Name:

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Notes: (please explain all answers marked other or enter contributions here)

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Life / AD&D

Contribution? ( (If Contributory please add your $ amount per employee? In notes)

Option 1

Multiple of Earnings? Yes or No? Yes how much earning on all employees? to what max amount?

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Class Plan ( list benefits below)?

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LIFE REDUCTIONS :

(If other please e

xplain in the note

s section)

Optio

n 1

Extended Death Benefit (Groups2-9)

Option 1

Waiver of Premium (Groups 10+)

Option 1

Dependent Life Amount? Yes or No? If yes enter amount?

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Life Claims Experience Attached (Groups 150+)

Option 1

Short Term Disability

Contribution (If Contributory please add your $ amount per employee? In notes)

Option 1

Percent of Earnings? Yes or No? If Yes What is the %?

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Flat Amount? No or Yes? If yes: list the $ / wk on all full time employees?

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Class Plan (list benefits below)?

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# day(s) accident?

# days sickness?

# of weeks?

1/8/13 or 1/8/26 (standard)?

Option 1

STD Claims Experience Attached (Groups 100+) ?

Option 1

Notes: please explain any necessary questions marked other or contribution amounts

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Long Term Disability

Contribution? If Employer Contributory please add amount contributed in notes)

Option 1

Percent of Earnings Yes or No? _______% of earnings to $________monthly benefit of full-time employees (standard)

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Class Plan (list b

enefits below) ?

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lputate nonummy. Maecenas

tincidunt lacus at velit.

Current Rate per $100

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Renewal Rate per $100

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Elimination Period

Option 1

Benefit Integration

Option 1

Benefit Duration

Option 1

Own OCC Definition

Option 1

LTD Claims Experience Attached (Groups 200+)

Option 1

Medical Gap

Contribution? If Employer Contributory please add amount contributed in notes)

Option 1

In-Hospital Benefits Plan 1

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Outpatient Benefit

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Physician Benefit

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