Request a Proposal

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

* Required Field

Step 1. Contact Information


Step 2. Basic Information

Approximate Number of Total Company Employees
*ArmadaCare services companies with more than 10 employees.


Required Effective Date

// (MM/DD/YYYY)
The Required Effective Date of Coverage must be the 1st day of the month, and at least 30 days from today's date.

Underlying Plan Information

Single OptionDual OptionTriple Option
Other 

Step 3. Attach Underlying Plan and Census Information

If you prefer to attach a pdf plan summary document and executive census file please do so now and then proceed to step 6. Otherwise please proceed to step 4 to fill in the balance of this form.

click here to add another attachment


click here to add another attachment


Your census file must include the following information:
  • Employee name (prefered but optional)
  • Gender
  • Date of birth
  • Zip code of executive (if different from home office)
  • Coverage type for underlying plan (family, ee +spouse , ee only)
  • Underlying medical plan option (if more than one plan is offered)

Supplemental Information for Large Plans (15+ Executives)(complete if applicable)

%

Vision and Dental Plans:

Dental Plan :  Company PaidVoluntaryNot Offered
Vision Plan :  Company PaidVoluntaryNot Offered

Step 4. Complete this section only if you did NOT attach a plan summary

Please complete the following Basic Medical Plan Information
Plan Type (select one):
PPO, POS, and HMO'S with In and Out-of-Network benefits
HMO, EPO etc. with NO Out-of-Network benefits
Deductible:    
Individual In-Network Deductible
Family Deductible Multiple
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 Type Drug Co-Pays
  Generic Preferred Non-Prefered
3 Tier
  Generic Brand  
2 Tier  
Notes on Drug Plan:
 

Step 5. Census Information (complete only if no file has been attached)

(Ages as of the Required Effective Date)
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

Step 6. Optional Information

Is there a Medical Reimbursement Program currently in place?
 
If yes, can you provide historical claims information?
 

Step 7. Submit