Coverage Evaluation
Ask Your Broker | Coverage Evaluation
Eastern Benefits Group Offers a FREE, NO OBLIGATION Evaluation of your company's existing coverage.
To see if your firm is getting the best value for your money and offering the right combination of benefits to your employees, please complete the Form below.
Once you have filled out the form, click on the SUBMIT button below.
We will respond with our analysis within five business days.
Note: If possible, please send us an employee census in the form of an Excel worksheet with the following information for each employee:
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gender
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date of birth
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home zip code
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current enrollment type (s = employee coverage only, s+1 = employee plus one, f = family)
You can send this information as an email attachment or fax it to 978.741.7035
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Who is your current health plan provider?
What type of plan(s) do you currently have?
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HMO POS (Point Of Service) _____PPO (Point Provider Organization)
What type of plan(s) would you like to offer?
____
HMO POS (Point Of Service) _____PPO (Point Provider Organization)
Please complete the following regarding your current plan(s)
| In Network | Plan 1 | Plan 2 |
| Office Visit Co-payment | ||
| Inpatient Hospital Co-payment | ||
| Emergency Room Co-payment | ||
| Prescription Drugs | ||
| Generic Drugs | ||
| Formulary Brand | ||
| Non-formulary Brand | ||
| Out of Network | ||
| Annual Deductable | ||
| Co-insurance percentage | ||
| Maximum out-of-pocket expense |
Please provide current monthly premium rates for your plan(s).
| Plan 1 | Plan 2 | |
| Individual | ||
| 2-Person (if applicable) | ||
| Family | ||
| What is your renewal date? |
Please provide the following company and contact information.
Name of company:
Address:
Business Type:
Contact Person:
Title:
Phone Number:
Email Address: