Framework Health Plan - Limited Medical Coverage

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Request For Quotes

Requested By

Agency/Agent
Phone Number
Email

Group Name
Type of Industry
Target Effective Date
State

Carrier

Standard Security Life

Nationwide Life

Total Number of Employees
Number of Eligible Employees
Description of Eligible Class

Employer Contribution Amount
Quote Request for		Employer Paid Rates Voluntary Rates (Nationwide requres a minimum 100 eligible lives)

Current Plan in Place

		YesNo
If yes, please answer the following:
Name of Carrier
Renewal Date
Renewal Date Action (explain)
Number of Current Enrolled
Is Census Available?		YesNo

Number of Plans to be offered

Standard Security Life		1 (1-50 Eligible)2 (51-250 Eligible)3 (251+ Eligible)
Nationwide Life		1 (1-50 Eligible)2 (51-500 Eligible)3 (500+ Eligible)

Enrollment Method

PaperFeed (100 enrolled minimum)OnlineCall Center (1,000+ Eligible)

If Call Center, will census be provided? YesNo

Bill Type

Monthly Semi-Monthly Bi-Weekly Weekly

(Payroll Cycle Plans Require Minimum 1,000 Eligible LIves)

Other Products

The Health Savings Program is included in all plans. It includes discounts on Chiropractic, Hearing, Nurse Hotline, Phone Counseling, Vision, Vitamins and Nutritional Supplements
Additional Benefit Options:

Tiered RX Aetna Dental Beech Street Point of Service Network

Critical Illness Program

Beech Street Viant Network (Standard Security Life Only)

First Health Network (Nationwide Life Only)

Optional Benefits (1,000+ Eligible Lives)

Nationwide Life		Dental/Vision Dental STD Life
Standard Security Life		Dental/Vision Dental Vision STD Life

Stand Alone Benefits (1,000+ Eligible Lives)

Nationwide Life		Dental
Standard Security Life		Dental/Vision Dental STD

Comments

Quotes are provided within 24-48 hours of receipt.

Groups with over 1000 eligible lives may require additional information and additional time to complete.