REQUEST FOR PROPOSAL – INDIVIDUALS & FAMILIES
NAME OF INDIVIDUAL:________________________________________________________ HOME ADDRESS:______________________________________________________________ CITY: _________________ STATE:_______________ ZIP:____________ COUNTY:_____________ DAYTIME PHONE NUMBER:________________ DATE OF BIRTH:____________ SEX: M or F SMOKER: Y or N HT:______ WT:______
NAME OF SPOUSE:____________________________________________________________ DATE OF BIRTH:____________ SEX: M or F SMOKER: Y or N HT:______ WT:______ SEX: M or F SEX: M or F SEX: M or F SEX: M or F
CHILD #1:________________________ DATE OF BIRTH:_____________ CHILD #2:________________________ DATE OF BIRTH:_____________ CHILD #3:________________________ DATE OF BIRTH:_____________ CHILD #4:________________________ DATE OF BIRTH:_____________
WHAT KIND OF INDIVIDUAL PLAN ARE YOU LOOKING FOR?
MEDICAL:_____ HSA:_____ DENTAL:_____ VISION:_____ LIFE:_____
MATERNITY RIDER:_____ DEDUCTIBLE’S: $500:____
OFFICE VISIT COPAY:_____ $1,000:____ $1,500:____
PRESCRIPTION RIDER:_____ $2,500:____ OTHER:_______
WHAT EFFECTIVE DATE ARE YOU LOOKING FOR?__________________________________ DO YOU CURRENTLY HAVE HEALTH INSURANCE?_____ WITH WHOM?_______________
ARE YOU SELF EMPLOYED?
WOULD YOU LIKE A ONE PERSON GROUP QUOTE? Y or N
NAME OF YOUR BUSINESS: ____________________________________________________ ADDRESS IF DIFFERENT FROM ABOVE:___________________________________________ ___________________________________________ TYPE OF BUSINESS:___________________________________________________________ SIC CODE #:_______________ FEDERAL ID #:___________________________________
SeaGate Benefits Administrators, Inc. 1760 Manley Rd, Maumee, Ohio 43537 419-887-6222; fax 419-893-5764; info@seagatebenefitsadministrators.com