FB Healthcare

Health Care Plans
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COMPANY TO BE QUOTED

Company Name:

Type of Business:

SIC Code:

City state zip:

County:

Phone Number:

Website:

WFB Membership Type:

WFB Membership #:

Cooperative Affiliations:

Current WFB Retro/Safety Program Member:

Yes

GROUP REPRESENTATIVE OR AGENT REQUESTING THE QUOTE

Contact Name:

Title:

Address:

City State Zip:

County:

Contact Phone:

Fax:

Email Address:

Requested Effective Date:

Current Agent:

# of Employees:

Comments:

CURRENT MEDICAL/DENTAL COVERAGE

Employer Contributions:

Employee Coverage: %

Dependent Coverage: %

Current Medical Carrier:

Name of Product:

Office Visit Copay:

Medical Deductible:

Coinsurance %:

Renewal Date:

Annual Out of Pocket Limit:

Vision Coverage:

Current Dental Carrier:

Dental Coinsurance %:

Dental Deductible:

Dental Max. Benefit / Person:

CURRENT AND RENEWAL RATES

Medical Coverage Plan 1

Employee

Current Rates:

Renewal Rates:

EE/Spouse

Current Rates:

Renewal Rates:

EE/Child

Current Rates:

Renewal Rates:

EE/Family

Current Rates:

Renewal Rates:

Dental Coverage

Employee

Current Rates:

Renewal Rates:

EE/Spouse

Current Rates:

Renewal Rates:

EE/Child

Current Rates:

Renewal Rates:

EE/Family

Current Rates:

Renewal Rates:

Medical Coverage Plan 2

Employee

Current Rates:

Renewal Rates:

EE/Spouse

Current Rates:

Renewal Rates:

EE/Child

Current Rates:

Renewal Rates:

EE/Family

Current Rates:

Renewal Rates:

FB Healthcare

Health Care Plans
Request a Quote

hc_reform

eFARMation

FB Healthcare

Health Care PlansRequest a Quote

hc_reform

eFARMation

Health Care Plans
Request a Quote