COMPANY

Name:

City:

   Zip:

(Please be specific)

Name:

  Phone:

        PLAN DESIGN

Deductible

500 1,000 2,000 5,000 Other

Cost Share

90/10 80/20 70/30 50/50 Other

Stop Loss

5,000 10,000 15,000 20,000 Other

Drug Card

Discount Deductible +copay Copay + percentage Copay Only

Dr. Visit Copay

None Limited Unlimited

Maternity

Yes No

Group Life

Yes No

Sup Accident

None 300.00 500.00

        Please Quote All Checked:

Aetna   Allied   Avemco (IAC)  Best   Blue Cross  Fortis  Health Market

  Humana   John Alden   Pacific Life  Principal  UniCare United Health

EMPLOYEE CENSUS

Name

1

Male Female

2

Male Female

3

Male Female

4

Male Female

5

Male Female

6

Male Female

7

Male Female

8

Male Female

9

Male Female

10

Male Female

11

Male Female

12

Male Female

13

Male Female

14

Male Female

15

Male Female

16

Male Female

17

Male Female

18

Male Female

19

Male Female

20

Male Female

21

Male Female

22

Male Female

23

Male Female

24

Male Female

25

Male Female