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Health Plus Consulting Services, Inc.
7922 Summa Ave. Suite A2 · Baton Rouge, LA 70809 · Phone:
225-612-2323 * Fax: 225-612-2324
2322 N. Arnoult Rd. Suite 200 · Metairie, LA 70001 · Phone: 504-835-2124 *
Fax: 504-835-2195
REQUEST FOR GROUP PROPOSAL ** In addition, please print and fill
in a Census.
Name of Group _____________________________ Requested Effective Date __________
Address _______________________ City __________________ State ______
Zip_______
Phone _____________ Fax __________________Group Industry _____________________
Number of Full-Time Employees ______ Number of Employees Presently Insured_________
EE (Only) ___________ EE/Spouse ___________ Family __________ EE/Child(ren)______
Current Carrier__________________________ Waiting Period________________________
Current Benefits_____________________________________________________________
% of Employer Contributions: Employee ___________% Dependents ___________%
Are there any employees covered under COBRA? ___________ If yes, how many
__________
1. Were there any employees or dependents who incurred medical expenses of $5,000 or more during the last 12 month period? YES _______ NO ________
2. Are there any physically handicapped dependents over age 19 covered by the current carrier?
YES _________ NO __________
3. Are there any employees or dependents to be covered under the proposed coverage who currently have serious health problems? (For example, but not limited to: cancer, heart trouble, neuromuscular disorder, AIDS, kidney trouble, paralysis or diabetes) YES ______ NO _______
4. Are there any active maternity cases? YES _________ NO __________
5. Is there anyone on disability or on waiver of premium status? YES ________ NO _________
6. If the answer to any of the above is YES, please give details including:
NAME: ______________________________________
Health Conditions (Dates)/Type of Treatment and Charges:
___________________________
_____________________________________________________________________________
_____________________________________________________________________________
__________________________
____________________________
_______________
Name of Agent
Signature of Agent
Date
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