REQUEST FOR PROPOSAL Please fill in the form below

							                                       REQUEST FOR PROPOSAL
                   Please fill in the form below by entering requested information into shaded areas.


Company Name:                                                                              Date:
Address:
City:                                                                 State:               Zip:
Web Address:

Contact Person:                                              Phone:
Fax:                                                         E-mail:

Owner’s Name:                                        Business Type:                     Years in Business:
FEIN:                                                        UCT#:
Pay Cycle:                        Payday:                         Cutoff:                    Delivery:
Bonuses Paid?        Description of the Operation:
Yes      No
                               Complete table below for each business location*:
 State          Class Code          Full-Time EEs             Part-Time EEs                    Total Wages




Total # of Locations:                 Total # of States Operating In:                 *Please list additional on separate sheet



Current Healthcare Carrier:                              Renewal Date:          Plan Types:      HMO                  PPO
Employer Contribution ($ 0r %):                                     Number of carriers in last 5 yrs:
Eligibility Criteria (hours for full time):
        Please specify if the following ancillary benefits are currently offered, or if requesting information:
Health          Currently offered         Subsidized?       Amt   $             Request Info            No Interest
Life            Currently offered         Subsidized?       Amt   $             Request Info            No Interest
Dental          Currently offered         Subsidized?       Amt   $             Request Info            No Interest
Vision          Currently offered         Subsidized?       Amt   $             Request Info            No Interest
ST disability   Currently offered         Subsidized?       Amt   $             Request Info            No Interest
LT Disability   Currently offered         Subsidized?       Amt   $             Request Info            No Interest
FSA             Currently offered         Subsidized?       Amt   $             Request Info            No Interest
401 K           Currently offered         Subsidized?       Amt   $             Request Info            No Interest
EPLI            Currently offered         Subsidized?       Amt   $             Request Info            No Interest
Section 125     Currently offered         Subsidized?       Amt   $             Request Info            No Interest

Current WC Carrier (or PEO):                                                          # of yrs with carrier:
Are any employees exempt from WC coverage:             Yes                      No
Does the prospect have EPLI coverage in force?         Yes                      No
Sub-Contactors used?        Yes    No       If Yes, % of Payroll?
General Liability (GL) Carrier:                                                 Limit of GL Liability: