Please fill out the information below to request a medical proposal.

 

Name of firm

 

Contact Phone #

 

Contact Email

 

Address of firm

 

Type of work Choose Option Davis-Bacon SCA State Prevailing Wage

 

Amount of Fringe

 

Jobsite(s)

 

Current Carrier

 

Current Benefits

 

Current Rates

 

Renewal rates

 

Renewal Date

 

Desired benefits

Medical
Dental
Vision
Life
Chiro

 

Please include Census Data and Risk Appraisal information. To view samples of each, please click the relevant link.

 

Click here to download the Census Data sample document.
Click here to download the Risk Appraisal sample document

 

*NOTE: If you have information in a different format than the Census Data and/or Risk Appraisal sample Word document provided then we will contact you to recieve your information.

 

Please attach your completed Census Data document

 

Please attach your completed Risk Appraisal document

 

Additional Information

 

Please attach a schedule of current benefits

 

Please type the letters of the image presented (they are case sensitive).   

 

 

Note: Information contained in this electronic transmission, including attachments, may include protected health information (PHI), confidential and/or proprietary information. It is intended only for the use of the individual or entity to whom it is addressed or individuals designated to view such information per HIPAA regulations. If the reader of this message is not the intended recipient, you are hereby notified that dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error please notify us immediately by telephone and return the original message to us at the address above.