Ameritas Proposal Checklist

v:\gruw\new case\Ameritas proposal checklist.doc 8/16/10

Send RFP’s via email to: or Fax to 402-309-2585

v:\gruw\newcase\prchklst.wpd - v:\group:\group forms\proposal checklist 8/16/10

Sales Office/Rep:
Phone: / Date Received Home Office:
Rates Due to Sales Office:
1. Group Name:
2. City/State: Zip:
3. Nature of Business? / Current/Estimated Enrollment
(If multiple locations, please provide the zips on disk/e-mail)
SIC Code:
4. In-Force Carrier: / In force Carrier Effect Date:
If less than 2 years with current carrier, who was previous?
5. Agent/Broker:
Does Broker have business with us now? Yes No / Broker of Record: Yes No
Commission Requested: Standard scale Net
Other Commission Currently Received:
If the policyholder is to be a M.E.T, Union, or Association, complete and send in appropriate questionnaire (GR 5457)
REQUIRED EXPERIENCE DATA (Must be attached for takeover cases)
1. 2-3 years Premium/Claims/Lives OR Claims/Lives (by month, preferably)
2. Rate History; current, renewal, and prior If not available, why?
(Please include the effective date of the rates)
3. Sales Office Ratesheets of the Current & Proposed Plan Options
4. Copy of In-Force Carrier Booklet
Any plan changes in the last 2-3 years? Yes No If yes, please include the date and description of change:
5. Rep Sales Strategy/Memo outlining pertinent sales information, requested plan design, etc.

COVERAGE AND BASIC RATING INFORMATION

1. Dental / ASO / Fully Insured / FUSION Soundcare LASIK
EyeCare / ASO / Fully Insured
2. Requested effective date? Why out to bid?
3. Eligibility: Standard 30 hrs. per week Yes No Other:

4. Rate structure requested: EE only 2-tier 3-tier 4-tier Grand Composite

No. Eligible / No. Covered / Percentage / Employer Contr.
Employee
Dependents (by current
rate structure) / sp / +1
ch / +2
fam

PLEASE NOTE: If there is more than one plan in-force, please provide the ee & dep participation in each plan.

Geographic Accessibility Requests– send to () with electronic census

Questionnaire/RFP Assistance – send to Group Questionnaire Inbox ()

Section 125 Plan Information (if applicable):

What does the employer contribute to the medical plan? EE Dep Other Benefits?

Section 125 Plan Year: to -- Election Period:

Mandatory Enrollment Meetings? Yes No Home Office help needed for enrollments? Yes No

Notes:

v:\gruw\newcase\prchklst.wpd - v:\group:\group forms\proposal checklist 8/16/10