MLJ-CO-RFP-SF-LFP-PEO-Markets-RFP-9-23.xlsx

	B	D	E	F	G	H	I	J	K	L
1
2	Request For Proposal Form Large Group Fully Insured, Level Funded
3
4
5
6
7	Broker Information
8
9		Agency Name	MLJ Financial Services, LLC						Date
10		Broker Name	Mary Heidbrier						Due Date
11		Broker Email	mah@mljinsurance.com
12		Address	210 W Cleveland st
13		City, State, Zip	Lafayette CO 80026						Broker of Record	Yes No
14
15		Commissions	Medical	Dental	Vision	Life	STD	LTD
16			$35	Standard	Standard	Standard	Standard	Standard
17
18	Group Information
19
20		Legal Name of Group							Effective Date
21		Headquarters Address							Renewal Date
22		County
23		City, State, Zip
24		Nature of Business/SIC					If multiple locations, please provide zip codes
25		Years in Business					If multiple locations, please provide zip codes
26		Group Tax ID Number
27		# of FTE's					Waiting Period
28		# of Eligible Employees
29		# of Enrolled Employees						Is this a carve out?		Yes No
30		# of COBRA Participants	0				Describe the eligible class
31			(Please indicate COBRA members on census in column provided)				Describe the eligible class
32	Reason for Quote		Market check		Intent To Move		Unknown
33	Plan Information
34
35	CARRIER HISTORY
36
37	No Current Medical Insurance
38			Carrier Name		Type of Coverage		Period of Time Insured
39									f Current Carrier
40									f Prior Carrier
41
42			Carrier Name				Period of Time Insured
43		Dental			No Current Dental				f Current Carrier
44		Vision			No Current Vision				f Current Carrier
45		Life/AD&D			No Current Life/AD&D				f Current Carrier
46		STD			No Current STD				f Current Carrier
47		LTD			No Current LTD				f Current Carrier
48
49	EMPLOYER CONTRIBUTIONS
50
51			Medical
52			Plan 1	Plan 2	Plan 3	Dental	Vision	Life/AD&D	STD	LTD
53		Employee
54		Dependents						n/a	n/a	n/a
55
56	RATES
57
58					EE	ES	EC	EF
59			Medical Plan 1	Plan Name
60				Current
61				Renewal
62
63			Medical Plan 2	Plan Name
64				Current
65				Renewal
66
67			Medical Plan 3	Plan Name
68				Current
69				Renewal
70
71			Dental	Plan Name
72				Current
73				Renewal
74
75			Vision	Plan Name
76				Current
77				Renewal
78
79			Life/AD&D STD & LTD		Life Rate	AD&D Rate	STD Rate	LTD Rate
80				Current
81				Renewal
82
83
84
85
86		Medical Carriers & TPAs			Fully Insured	Level Funded	Self Funded	Dental/Vision	Life/AD&D	STD/LTD
87		Aetna			n/a	2-100	n/a		n/a	n/a
88		Anthem			2+	10+
89		Cigna			100+	20+			n/a	n/a
90			CoAdvantage PEO		5+	n/a	n/a
91			Gravie TPA		n/a	n/a	15+	n/a	n/a	n/a
92			HealthEZ TPA		n/a	n/a	25+		n/a	n/a
93		InTantem PEO			10+	n/a	n/a
94			Justworks PEO		2+	n/a	n/a
95		Kaiser Permanente			2+	20-100	n/a	n/a	n/a	n/a
96		UnitedHealthcare			2+	10+
97			39North		n/a	n/a	25+	n/a	n/a	n/a
98		Ancillary Carriers			Dental		Vision		Life/AD&D	STD/LTD
99		Ameritas							n/a	n/a
100		Beam							n/a	n/a