Enterprise Underwriting Services


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Request a Quote

A request for proposal may be submitted using the form below or as an attachment sent to the following e-mail address:

All information needs to be completed.
REQUESTING TPA/BROKER

Name
Address
Submitted By
E-mail
Date Needed
Account Name
Account Address
Nature of Business

Is there more than one location? No Yes
If Yes, then provide for each location its zip code and number of employees (i.e. 15220/136, 92110/84, etc.)

DESIRED STOP-LOSS QUOTE

Effective Date

Anniversary Date

Commission

Specific Deductible

1) 2) 3)

Aggregate Coverage?

No Yes

Covered Benefits

Medical	Dental	Vision
Rx Card	Rx Mail	WI
Other

Stop-Loss Contract Basis

Type	Specific	Aggregate	(No)
12/12
12/15
15/12
Paid
Other
Individual Advancement? No Yes

PRESENT PLAN

Currently Self-Funded?	No Yes
Current Carrier

	Employee	Dependent	Family
Current Premium
Renewal Premium

EMPLOYEE INFORMATION

Total Employees	Total Singles	Total Dependents
# of Employees in HMO	# of Employees in PPO	# of Employees in COBRA
# of Retirees Covered	# of Disabled Covered

PRESENT BENEFITS

Base Plus Plan Comprehensive Major Medical Plan PPO/POS/EPO

Deductible
Co-Insurance	% of the first then 100%
Plan Maximum
Drug & Alcohol Max
Additional Benefits

Quote:

	Present Plan
	Alternative Plan
	Both

Please do not transmit any personal health information via this form. Information submitted via this form may at times travel over non-secured lines and should not include personal health information or any other information that you believe to be confidential or personal. Any information submitted hereon may be viewed by individuals outside of Enterprise Underwriting Services (EUS). EUS disclaims all responsibility for the protection of privacy or security of any information submitted via this form.