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Request for Proposal

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Health Products

Allied Distributor Information:

Allied Distributor:

Name:

Date Proposal Needed:

Address:

Enrollment Start Date:

City, State Zip:

Full Proposal Needed:

Yes

Phone Number:

Rate & Underwriting Quote only:

Yes

Email:

Distributor/Broker Name on proposal:

Yes

Elec. Proposal:

Yes

Case Information Section: (* required information)

*Name:
*Domiciled State:
Address:
City, State Zip:	,
Phone Number:
Website:
*Nature of Business: (SIC)		Years in Business:
*# of Eligible Employees:
*Define Eligibility:		(hrs per week)
Number of Locations:		*States Located in:
Employee Turnover Rate:

*New Case

Renewal

Take Over

Competitive Bid

(mark all that apply)
*If Takeover: Current Carrier(s) with which product(s):

*Disability Income:

*Elimination Period:	0/7	7/7	14/14	30/30
	90	180

*Benefit Period:	3 Months	6 Months	12 Months	24 Months

*Coverage:

Off the Job Only

On & Off the Job

*Accident Insurance:


	*Riders:
		On the Job Only
		Off the Job Only
		On & Off the Job

(Other carrier specific riders available, contact NBP Website for more information)

*Cancer Insurance:

*Group Cancer Quote Requested:


	*Riders:
		Hospital Intensive Care
		30 more Specified Diseases
		Initial Diagnosis
		Wellness Benefit

(Other carrier specific riders available, contact NBP Website for more information)

*Critical Illness:

*Group CI Quote Requested:

*Riders:

Include Cancer

Reoccurance Benefit

Wellness Benefit

$25

$50

$75

$100

(Other carrier specific riders available, contact NBP Website for more information)

*Limited Medical:

*New

*Take-Over

Request Plan Design:

*Employee Contribution:

Yes

*Current Participation %:

* Prescription Drug Benefit:

Yes

*Total Eligible Employees or Members:

*Underwriting:

Gauranteed Issue:

Conditional Gauranteed Issue:

Simplified Issue:

Money Purchase or Face Amount:

Employee: Spouse: Children:

Special Request:

Enrollment Information:

*Name of Enrollment Firm:

Address:

City, State Zip:

Years in Business:

Proper License:

Yes

Effective Date:

Enrollment Start Date:

*Enrollment Method:

	Face-to-Face
	Web
	Paper or Electronic
	Call Center – inbound or outbound

	Electronic Pin
	Voice Stamp

Expected Participation:

*Billing Information:

*Employer: Administered by Allied Distributor: PCA: TPA:

Multiple Billing Locations:

Yes

How many locations:

Consolidated Billing needed: