Step 2 - We need more information.
If you would like to wait for us to contact you via email then you do not need to
continue and can exit now.
Otherwise please enter in all appropriate information below:

   
  Medical Health Plan #1 (Name)            
   
  Medical   HMO PPO     EPO   Indemnity                              
  Explain Benefit Level (100% Hospital, 90% / 70% Hospital - RX Drug Benefits, Any other detail)  
                         
(You may be asked to provide associated Benefit Design literature)  
  What is the premium rate for Employees only?                            
  What is the premium rate for Employees + Child(ren) only?                        
  What is the premium rate for Employees + Spouse only?  
  What is the premium rate for Employees + Family?    
  Is this plan Self Insured?     Fully Insured?        
     
  Medical Health Plan #2 (Name)  
Indemnity
Medical HMO PPO EPO
  Explain Benefit Level (100% Hospital, 90% / 70% Hospital - RX Drug Benefits, Any other detail)  
 
(You may be asked to provide associated Benefit Design literature)  
                                                                                                                     
What is the premium rate for Employees only?      
What is the premium rate for Employees + Child(ren) only?  
What is the premium rate for Employees + Spouse only?  
What is the premium rate for Employees + Family?  
Is this plan Self Insured?       Fully Insured?                
                                                                                                                     
Dental Plan Name    
Plan Type: Prepaid   PPO Dental       Indemnity Dental        
Explain benefit level if applicable                                                
 
(You may be asked to provide associated Benefit Design literature)  
What is the premium rate for Employees only?  
What is the premium rate for Employees + Child(ren) only?  
What is the premium rate for Employees + Spouse only?  
What is the premium rate for Employees + Family?  
Is this plan Self Insured?         Fully Insured?                    
                                                                                                                       
Vision Plan Name    
(You may be asked to provide associated Benefit Design literature)    
What is the premium rate for Employees only?  
What is the premium rate for Employees + Child(ren) only?  
What is the premium rate for Employees + Spouse only?  
What is the premium rate for Employees + Family?  
Is this plan Self Insured?     Fully Insured?                                    
                                                                                                                                       
Life Plan Name    
(You may be asked to provide associated Benefit Design literature)      
What is the life insurance rate?                                                    
How much coverage is offered to each employee? $ .00                                
Other information about this plan?                                                  
     
Is this a voluntary plan or is it company sponsored?                        
Voluntary Company Sponsored
Is this plan Self Insured?         Fully Insured?                
How much does your company contribute towards the employees insurance premiums?  
%                                                                                                                
Is this uniform policy throughout the company?   Yes   No              
 
 
Thank you,a representative from CompUsys Insurance Services, Inc. will be contacting you within 48 hours