Plans & Services

  Consulting Services
  Flexible Benefit Plans
  Direct Reimbursement Plans
  Electronic Enrollment & Eligibility
  Employee Communication
  Compliance Services



 

 

Direct Reimbursement
Request for Proposal

Cost estimate submitted by:  Broker    Consultant    Employer   

Name:
Company:  
Street Address: 
City:  State:    Zip:
Telephone:    Fax:
E-mail:

Cost estimate requested for:
Group Name:  
Benefits Manager:
Street Address:  
City:  State:    Zip:
Total number of employees (minimum of 25):

  
Check the tier level and list the number of employees for each level at the far right:

2-tier
3-tier
4-tier
# Employees 
 Employee Only
 Employee Only
 Employee Only
 Family
 Employee + 1 Dependent
 Employee + Spouse
.
 Employee + 2 More  Dependents
 Employee + Child(ren)
. .
 Family

Are all employees located at the above address?    Yes   No

If no, then list state, zip code, and number of employees at each site below:

State
Zip Code
# Employees
State
Zip Code
# Employees
State
Zip Code
# Employees
State
Zip Code
# Employees
State
Zip Code
# Employees














Current dental benefits offered?    Yes   No

If yes, since when?    

Type of Plan:    Indemnity    DHMO     DPPO    Self-Funded   

If group has a plan, include a breakdown of current benefits:

Current Insured Premium Rates
Indicate the Percentage
 Employee
$
  Eligible Employees Enrolled
%
 Employee + Child
$
  Eligible Dependents Enrolled
%
 Employee + Spouse
$
  Eligible Employees Not Enrolled
%
 Family
$
.
.

Indicate the percentage of the expected participation with a DR plan for:

    Employees     %           Dependents %

Proposed effective date of Direct Reimbursement Program: 

Estimated annual turnover rate:   %

What percentage of the employees are:

 % Clerical/Blue Collar employees?   
% Professional/Government?
% Teachers/Entertainers? 
% Semi-Skilled?
% Unskilled?    
% Union/Other?    

 100% = Total

What percentage of employees are female?   %
(Number of female employees/total number of employees)

What percentage of spouses are female?      %
(Number of female spouses/total number of spouses)

Through what age will dependent children be covered as students?    years

Will employee contributions be required?     Yes   No

If yes, please indicate how costs will be divided –

Employee Coverage:    Employee Pays   %    Employer Pays   %

Dependent Coverage:  Employee Pays   %    Employer Pays   %

Check the type of program:
   Freestanding Program
   Packaged Program (employees must participate in the medical plan)
 
Check desired plan(s) below:

Plan Design Number and Description
Maximum Benefit
Per Person Maximum
Per Family
Maximum

DR750

 100% of first $100; 0% of next $50;
 80% of next $250; 50% of next $900

$750

DR1000

 100% of first $100; 0% of next $50;
 80% of next $250; 50% of next $1,400

$,1000

DR1500

 100% of first $100; 0% of next $50;
 80% of next $250; 50% of next $2,400
$1,500

DR1500

 100% of first $100; 0% of next $50;
 80% of next $250; 50% of next $3,400

$2,000
Custom 1
Custom 2
Custom 3

 


















 

 

Include Orthodontics   Include Vision $ Maximum

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