Group Proposal Request Form
Today‚Äôs Date:  19/April/2014 Needed Date: Proposed Effective Date:
 
Company or Fund Name:
Address:
City:
  State: Zip:
Number of Employees:
Contact Name:
Title:
Phone:
Current Plan:
Carrier:
Fax:
Email:
Rates:
Do You Use A Broker or Consultant?
If Yes, Name of BROKER/CONSULTANT: 
Agency:
Address:
City:
  State: Zip:


PLAN TYPE (Check ONE): Service Benefit Frequency (in months)
 
Exam
24
12
12
Lenses
24
12
12
Frames
24
24
12
Contacts
24
12
12


COPAYMENT AMOUNT:
Zero |   $10 |   $15 |   $20 |   $25 |   $35
Company Pays All minimum group size 10
Company Pays Employee / Optional Dependent minimum group size 10
Total Flex * minimum group size 50
Other Comments/Instructions:
 
 
 
* minimum group size and participation requirements apply, unless packaged with your medical, dental or prescription drug plan.