Benefits RFP

General Information

# of Employees

Current Coverage (Check all that apply)
Plans Requested (Check all that apply)

Underwriting Information

Please answer the following questions to the best of your knowledge, while remaining HIPPA compliant (do not discolose names of any employee or dependent).
Check all that apply

Required Documentation

ALL items listed below must be provided to Benefits Division before submission to markets. Underwriters may also request additional information after submission, in which your prompt response to these inquiries is needed to complete the quoting process timely.

Please Note Average Turnaround Expectations, by Carrier Market Segment:

Small Group: 5-50 Employees 2-3 business days
Mid-Market: 51-99 Employees 5-10 business days
Large Group: 100-500 Employees 2-4 weeks

Upload requirements

Plan(s) Rates (by coverage tier, EE/ES/EC/FAM)
Maximum upload size: 52.43MB

Summary of Benefit Coverage(s)
Maximum upload size: 52.43MB

Carrier Renewal Notice with new Rates * if within 60 days for Small/Mid-Market * if within 90 days for Large Group
Maximum upload size: 52.43MB

Current Carrier Invoice(s)
Maximum upload size: 52.43MB

Payroll Journal/Benefits Register with deductions
Maximum upload size: 52.43MB

Please upload your Employee Census (Include enrolled dependents/spouses) if you have one. To download our census template click here.

Maximum upload size: 52.43MB

If > 50 employees

ACA Full-time Eligible Report
Maximum upload size: 52.43MB

Claims History by Month, past 2-3 years
Maximum upload size: 52.43MB

Large Claims > Greater than $10K Report - past 2-3 years
Maximum upload size: 52.43MB

Have questions? Reach out to us…