* Request Proposal
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Request a Proposal

Please fill in this form or Contact Us to submit needed information about your group via email or fax

*Required Field


Check if you are an agent or a broker.

Employer Group Information (Note: ArmadaCare will not contact your client directly unless you request it)
Name of Employer: *
 Main Phone: *
 
Address:*
 Main Fax:
   
City:*  
Zip:*
 
Primary Contact
Name:*
 Phone:*
Email:*
 Fax:
 
Notes:
 
Approximate Number of Total Company Employees:
*ArmadaCare services companies with more than 10 employees.
 
Required Effective Date
Required Effective Date of Coverage: / /  (MM/DD/YYYY)
The Required Effective Date of Coverage must be the 1st day of the month.
 
Underlying Plan Information

Number of Medical Plan Options Offered :

Single Option Dual Option Triple Option
Other  
 
 
Please complete the following Basic Medical Plan Information
Plan type (select one)
PPO, POS, and HMO'S with In and Out-of-Network benefits

Network Benifits HMO, EPO etc. with NO out-of-network benefits

Deductible:        
Individual In-Network Deductible
Family Deductible Multiple
2x
3x
Co-Insurance:        
In-Network Co-Insurance%
Annual Out-of-pocket Maximum: (OOP)        
Individual, In Network OOP. maximum
 
Drug Plan Information: (complete if applicable)
Drug Plan Deductible
Drug Plan Type Drug Co-Pays
  Generic Preferred Non-Prefered
3 Tier
  Generic Brand  
2 Tier  
Notes on Drug Plan:
 
Supplemental Information for Large Plans (15 + Executives)
(complete if applicable)
Supportable In-Network Utilization % of Underlying Medical Plan:
 
Vision and Dental Plans :
Dental Plan :   Company Paid Voluntary Not Offered

Vision Plan :  Company Paid Voluntary Not Offered

 
Do you Currently offer a Medical Reimbursment Program to Executives?
yes no  
   
Census Information (Ages as of the Required Effective Date) Fill in this form or see below to attach file.
Age Grouping Emp Only Emp +
One		 Emp +
Children
Emp +
Family
M F M F M F M F
< 30 yrs
30-34 yrs
35-39 yrs
40-44 yrs
45-49 yrs
50-54 yrs
55-59 yrs
60-64 yrs
65+ yrs
 
If you prefer to attach a file, we need the Following information about your participating executives to process a quote.

Please attach an excel document with the following

  • Employee ID:(optional)
  • Employee Name (optional but preferred)
  • Male/Female
  • Date of Birth
  • Zip Code of the Executive (if different from home office state)
  • Coverage Type Election of underlying health coverage
  • Medical Plan Option (A unique descriptor helping us know who is covered by what plan)

You may attach your Medical Plan Benefits Summaries to this form by uploading your file. (Only text, Word, or Excel documents are allowed.)
 
   


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Armada Care, a provider of executive health programs, offers executive medical reimbursement plans that can assist top executives with maintaining health and high productivity. Please contact us to learn more about our benefit programs for top executives or request a proposal.