-- Request Proposal
-- Request Proposal
-- Request Proposal
Request for Proposal
All
Specialized Products
Allied Distributor Information:
Allied Distributor:
Name:
Date Proposal Needed:
Address:
Enrollment Start Date:
City, State Zip:
,
Full Proposal Needed:
Yes
No
Phone Number:
Rate & Underwriting Quote only:
Yes
No
Email:
Distributor/Broker Name on proposal:
Yes
No
Elec. Proposal:
Yes
No
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):
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
No
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
No
How many locations:
Consolidated Billing needed: