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PLEASE INCLUDE THE FOLLOWING WHEN SUBMITTING A REQUEST
FOR PROPOSAL TO SLG BENEFITS & INSURANCE, LLC.

Official name of the employer
Location of the group (City, State, Zip)
Desired effective date of coverage
Quote due date
Specific deductible (current and proposed)
Contract type (current and proposed)
Commission level requested
Current census (including year of birth or age, sex and type of coverage- if Cobra, Retiree or Disabled please designate accordingly)
If the employer has multiple locations, include the number of employees in each location with corresponding zip code.
Nature of business and/or SIC code
Schedule of current benefits and proposed benefits, if different. (note which coverages are to be included under the specific and aggregate contracts)
Monthly paid claims and enrollment (month by month aggregate report for the most recent 24 month minimum)
Current and/or renewal rates (whether self-funded or fully insured)
If fully insured with no paid claims experience, provide current and renewal fully insured rates on groups up to 250 lives.
Shock claims in excess of 50% of the current deductible and any serious ongoing condition including diagnosis/prognosis
PPO network and UR facility being implemented (if multiple networks, please specify by location). Please note the current PPO network if different than the proposed.
Ancillary coverages requested (i.e. Aggregate Accommodation, Terminal Liability or Split-Funded Specific.)

Copyright ©2008 SLG Benefits & Insurance, LLC