Thank you for your EBS Bridge Program™ Request for Proposal

Please attach census and current month's billing of the major medical carrier with this submission. Please call us with any questions at 601.353.0002, ask for the Proposals Department. You can also email us at proposals@ebs17.curleydesign.com

Employer Information

Employer Name

Street

City

State

Zip

Effective Date

Industry

Agent Information

Agent Name

Send Proposal to

Agent Phone

Agent Fax

Enrollment

Employee Only

Employee & Spouse

Employee & Child

Full Family

Total:

*Required field

In-Force Major Medical

Current Major Medical Carrier

Current Major Medical Benefits

Current Premium Rates

Renewal Premium Rates

Deductible

Coinsurance (Insurance Pays)

Total Out of Pocket (including deductible):

Physician Co-Pays

Rx Deductible

Rx Co-Pays

E.R. Co-Pay

Other

Employee Only

Employee Spouse

Employee Child

Full Family

Employee Only

Employee Spouse

Employee Child

Full Family

Proposed Major Medical

Proposed Major Medical Carrier

Proposed Major Medical Benefits

Proposed Premium Rates

Deductible

Coinsurance (Insurance pays)

Total Out of Pocket (Including deductible)

Physician Co-Pays

Rx Deductible

Rx Co-Pays

E.R. Co-Pay

Other

Employee Only

Employee Spouse

Employee Child

Full Family

Requested EBS Bridge Benefit 1

Physician Office Benefit

Prescription Drug Benefit

Bridge Deductible

Bridge Coinsurance (Bridge Pays)

Bridge Total Out of Pocket (Includes deductible)

Bridge pay on the Primary co-pay

Bridge pay on the Specialist co-pay

Bridge pay

on the Tier co-pay

Special Considerations

Requested EBS Bridge™ Benefit 2

Physician Office Benefit

Prescription Drug Benefit

Bridge Deductible

Bridge Coinsurance (Bridge Pays)

Bridge Total Out of Pocket (Includes deductible)

Bridge pay on the Primary co-pay

Bridge pay on the Specialist co-pay

Bridge pay

on the Tier co-pay

Special Considerations

Additional Information Needed

Please attach census with this submission. Please provide: date of birth, sex, coverage (Single, Ee & Sp, Ee & Ch, Family). We do not need a name or Social Security number. Please attach the current month's billing of the major medical carrier with this submission. Please call us with any questions at 601.353.0002, ask for the Proposals Department. You can also email us at proposals@ebs17.curleydesign.com

Does this group have gap insurance?

Yes No

If yes, please indicate the carrier

Comments

Upload Census

Upload Current Billing from Major Medical Carrier