Group Health Insurance Proposal Request Council Services Pius, Inc. Retum this form to Council Services Plus, Inc., 272 Broadway, Albany, NY 12204, or fax to: (509)-562-4926 I. Your Organization Information Name of Agency. Address. Phone Contact Person, E-mail Address Total Number of employees ‘Number of eligible employees: (Those who work 20 or more hrs/week and are not excluded from benefits by your Personnel Policy.) I. Your Current Health Insurance Plan ‘Ifyou do not current offer group health insurance, you should move onto complete section III. Name of Carrier(s): What Month does your plan(s) renew? What is the Medical Office visit copa Do you have a hospital inpatient copay? How much is the copay for Prescription drugs What additional Riders do you have on yout Health plan student coverage? such as: Vision, Dental coverage, or Full time III. What coverage options would you like to see quoted? 1. Tier Structure - Provide a quote for Employee. Employee and Spouse __ Employee and Children Family Coverage _ 2. Medical Copay $15____$20____ $25, $30. Other_ 3, Hospital (inpatient) Copay $0. $240. $500. 4, Out of Network Coverage (if available) 80/20% 70/30% 5. Prescription drug coverage: No coverage. , Generic co-pay , Brand co-pay ____, Non-formulary co-pay Prescription Drug deductible? $0, $50. , $100, , Other 6. Other Rider Options you may need Full time student coverage Vision coverage___Dental coverage Mental Health enhancements ‘Alcohol/substance abuse enhancements Healthcare Reimbursement Accounts (HRA’s) can help you save on your health insurance costs. Ifyou would like more imformation, call CS Plus to discuss this exciting option. 518-434-9194, ext 128 or 1-877-501-4CSP