Current Medical Plan Design

Company Name: ________________________________________________________

Nature of Business: ______________________________________________________

City: ___________________ State: ___________ County: ________________ Zip: _________
 (Please Include Any Out-Of-State Locations)

Location 2: City: __________________________ State: ___________  Zip: __________

Location 3: City: __________________________ State: ___________  Zip: __________

Location 4: City: __________________________ State: ___________  Zip: __________
 
CURRENT PLAN DESIGN
LIFE & AD&D MEDICAL
Current Insurance Company:

__________________________

 Current Insurance Company:

__________________________
Life Schedule:
_______________________

_______________________

 Deductible:
Single: $________

Family: $________

 Coinsurance:


______% of first $_______

CURRENT RATE

RENEWAL RATE

Office Visit Copay (In-Network)

$_____________

 Hospital Confinement Deductible (If Applicable)
In-Network:                 
$_____________   		 Out-Of-Network:
$_____________  


Life $_______
Life $_______
AD&D $_______ AD&D $______
Drug Card Generic
$__________		 Brand
$__________		 Deductible
$__________
(If Applicable)
RENEWAL DATE CURRENT RATE RENEWAL RATE
_____/_____/_____ E     $______________
ES   $______________
EC   $______________
ESC $______________		 E     $______________
ES   $______________
EC   $______________
ESC $______________
  RENEWAL DATE: ______/______/_____

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