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Co-Pay
No Co-Pay
Employer Information:
Prepared By:
Prepared For:
Email:
Broker:
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Entity:
Zip Code:
City:
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Please select the number of members per age group
<65 Disabled:
Age 65:
Age 66:
Age 67:
Age 68:
Age 69:
Age 70 - 74:
Age 75 - 79:
Age 80 - 84:
Age 85+:
Under 65 disabled age group must be less than 10% of the total enrolled members.
Medical Plan Selection
$0 Deductible Plan
$100 Deductible Plan
$150 Deductible Plan
$250 Deductible Plan
$500 Deductible Plan
$750 Deductible Plan
$1000 Deductible Plan
$1500 Deductible Plan
$2000 Deductible Plan
$2500 Deductible Plan
$3000 Deductible Plan
$4000 Deductible Plan
Select All Plans
Prescription Drug Plan Selection
Preferred-Choice
Premier
None
When selecting a prescription drug plan, the enrollee must be part time or retired.
Optional Benefit Plan Selection
Private Duty Nursing
At Home Recovery
Comprehensive Wellness
Skilled Nursing
Select All Optional Plans
If any optional benefits are chosen by the employer at time of contract, all members enrolling are required to accept those optional benefits