Name of Business:

Nature of Business, SIC code if known:

Zip code of Business:

Phone:

Fax:

URL address:

Requested Effective Date
(dd/mm/yyyy format)

Number of Full Time Eligible Employees:

Number of Employees Participating in Health Plan
(min. 50% participation required):



Census Information for Participating Employees:
Initial estimates are calculated by the average age and gender of your
group. Final rates are subject to Medical Underwriting.

Group Medical benefit Options
Please select the benefit combination you prefer for your Group Medical
Policy. Please note:  Not all benefit combinations are applicable, Tailored
Business may have to suggest a close alternative, if certain benefit
combinations are no longer available.

1.) Network Selection:
Rural Network Urban Network

Health Savings Account Eligible:
Yes No

Deductible:
$100 $250 $500 $750 $1,000 $1,500 $2,000 $2,500 $3,000 $5,000

Out of Pocket Maximum:
$1,000 $1,500 $2,000 $2,500 $3,000 $4,000 $5,000 $6,000 $8,000 $10,000

CoInsurance:
80% 90%

Office Visit Copay
$10 $15 $20 $25 $30 $35 Ded/CoIn

Specialist Office Visit Copay:
$25 $40 $45 $50

Pharmaceutical Drug Benefit:
Yes No


Available Riders:

"Special Accident" - pays $500 of first dollar
medical expenses due to accidental injury:
Yes No

"Out Patient Surgery Benefit" - pays 100% for all Out Patient Surgery
Procedures. Or this may be left subject to the Deductible and Coinsurance:
100% Ded/CoIn

"Extended Wellcare" - Covers wellcare visits for adults and children over 6:
Yes No

"Emergency Room Copay" - You only pay $100 copay when visiting
the Emergency Room, If admitted charges are subject to the Deductible
and Coinsurance:
Yes No

Group Vision:
Yes No

Group Dental:
Yes No

Group Life Insurance:
Yes No

Group Short Term and Long Term Disability:
Yes No


Questions or comments: