Request for Proposal - Vision Plan of America

Request For Proposal

Name of Prospect

Location

Zip Code:

Nature of Business

Are you currently the Broker?

Yes No

Your Phone *

Your Name *

Does your prospect currently have Vision coverage?

Yes No

If Yes:

What is/are the current plan(s) (please include benefit summaries):

Prepaid:

Indemnity:

Current Rates:

Prepaid:
Single:
Couple:
Family:

Indemnity:
Single:
Couple:
Family:

Renewal Rates:

Prepaid:
Single:
Couple:
Family:

Indemnity:
Single:
Couple:
Family:

Total number of employees

Total number of eligible employees

Total number of participating employees

(Please include census)

What percentage of the Employee Premiums is the Employer Contributing?

What percentage of the Dependent Premiums is the Employer Contributing?

Requested Coverage:

Voluntary Employer Paid

Prepaid

Benefit Design; Deductible (if any):

Indemnity

Benefit Design; Deductible (if any):

Requested Effective Date

Broker Name:

Broker Fax:

* Required Fields