• Request for GAP Proposal

  • Instructions

    1. Complete this form. (You can request up to 3 plan designs per submission)

    2. Attach Current Census. (Census must include Employee Name, Sex, DOB and Coverage Tier.  Dependent information is NOT needed.)

  • Todays Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Quote Effective Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • AGENCY / AGENT INFORMATION

  • GROUP INFORMATION

  • PLANS DESIGNS

  • PLAN 1

  • Plan 1 - Is this a Shared Deductible (Shared Deductible plans require a minimum of $2,500)

  • PLAN 1 RIDERS

    (RIDERS NOT AVAILABLE IN ALL STATES)
  • Plan 1 - Office Visit Copays
  • Plan 1 - Office Visit Copays Start:
  • Plan 1 - Rx Benefit
  • Plan 1 - Rx Benefit Starts:
  • Plan 1 - Rx Copays

  • PLAN 2

  • Plan 2 - Is this a Shared Deductible (Shared Deductible plans require a minimum of $2,500)

  • PLAN 2 RIDERS

    (RIDERS NOT AVAILABLE IN ALL STATES)
  • Plan 2 - Office Visit Copays
  • Plan 2 - Office Visit Copays Start:
  • Plan 2 - Rx Benefit
  • Plan 2 - Rx Benefit Starts:
  • Plan 2 - Rx Copays

  • PLAN 3

  • Plan 3 - Is this a Shared Deductible (Shared Deductible plans require a minimum of $2,500)

  • PLAN 3 RIDERS

    (RIDERS NOT AVAILABLE IN ALL STATES)
  • Plan 3 - Office Visit Copays
  • Plan 3 - Office Visit Copays Start:
  • Plan 3 - Rx Benefit
  • Plan 3 - Rx Benefit Starts:
  • Plan 3 - Rx Copays
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