Business Broker Office - Excel by eek12905

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									Todays Date:                                                               Effective Date:
Group Name:                                                                Zip Code:
City:                                                                      SIC/Business:
Broker Co.:                                                                Broker Name:
Email/Fax #:                                                               Current Carrier:
                                                             MEDICAL MUTUAL OF OHIO
                                              Deductible
Tier Rate:                                                   Deductible
                               Office Visit                                Coinsurance          OOP In-Ntwk
                                                In-Ntwk         Non-Ntwk                                            OOP Non-Ntwk Single/Family
                                 Copay                                              In/Out      Single/Family
                                                             Single/Family




                                                    COSE - Standard $10k life - 10-99 Lives
                                                       All OOP Maximums exclude deductible amount
Please check desired plans: P
                                    Supermed Plus Options- Hospital and Professional Provider Network PPO
250 / 500                         $15                $250 / $500                80% / 64%      $1250 / $2500             $2500 / $5000
500 / 1000                        $15               $500 / $1000                80% / 64%      $1250 / $2500             $2500 / $5000
750 / 1500                        $20               $750 / $1500                80% / 64%      $1500 / $3000             $2500 / $5000
1000 / 2000                       $20               $1000 / $2000               80% / 64%      $1500 / $3000             $2500 / $5000


               Supermed Classic Gold Options- Any Hospital of Professional Provider w/ richer benefits if using a network hospital
SMC 250                           $15                $250 / $500                90% / 80%                       $1250 / $2500
SMC 500                           $15               $500 / $1000                90% / 80%                       $1250 / $2500
SMC 750                           $20               $750 / $1500                90% / 80%                       $1500 / $3000
SMC 1000                          $20               $1000 / $2000               90% / 80%                       $1500 / $3000


                            Supermed Multiple Option Products- Hospital and Professional Provider Network PPO
MOP 80                            $20         $100 / $200 $250 / $500           80% / 60%      $1250 / $2500             $3000 / $6000
MOP 90                            $20            None        $250 / $500        90% / 70%      $1250 / $2500             $3000 / $6000
MOP 100                           $15            None        $250 / $500       100% / 70%           None                 $1500 / $3000


                                                      HMO Health Ohio Products - PCP required
HMO Ohio                          $15                      None                    100%                             None




                                                                                              Please return completed quote requests to
        4200 Rockside Road, Suite, 300                                                              AMY JOHNSON or LISA KIGER
        Cleveland, Ohio 44131-2530                                                            Phone: 216-520-0440 Fax: 216-520-0444
        www.expresslinkga.com                                                                    Email: Ajohnson@expresslinkga.com

								
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