Employee Benefits Proposal Request

Company Name
Zip Code
Contact Name
Contact Phone
Fax
Do you have a current plan?	Yes No
Next renewal date
Health Plan Options Requested
Type
Co-Pay
Deductible
Co-Insurance (if applicable)
Hosptial Co-Pay (if applicable)
Note, 5 night max per illness, then cover 100%
Stop Loss

the Amwell agency