Employer:
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Are you seeking (check all that apply)?

Health claims adjucation services WC claims adjudication services Utilization Management Large Case Management Disease Management EAP Wellness Programming/Health Risk Assessment Dental Administration Vision Administration Flex/125 Administration Short Term Disability Administration Other

Flex Admin (Please Describe): Other:

Contract term requested:
Expected inception date:
Do you presently self-insure the lines checked above?	Yes No
If yes, which lines?

Please complete the following questions for a Group Health-Services quote:

Number of Employees eligible for health coverage:
Number of dependents eligible for health coverage:
Contributory coverage:	Yes No
Number of locations:
Jurisdictions/state(s) of operation:

If you are fully Insured:
Who is your current carrier
If you are Self Insured:
Who is your current administrator
# of yrs.
Who is your stop loss carrier
# of yrs.
Current specific level
Desired specific level
Aggregate factors
Renewal date
Rate history:
Current year
Prior year
Prior year
Claims experience:
Current year
Prior year
Prior year

Please complete the following questions for a Workers’ Compensation services quote:

Number of locations:
Jurisdictions/state(s) of operation:
Do you need assistance securing the right to self-fund in any or all states of operation?	Yes No If yes, in which states?
Interested in remote data access ?	Yes No
	If yes, to what extent?
Do you have a need for trust administration services, Security Bond or Excess Insurance purchase?	Yes No

Describe any other services of interest: