Partially Self Funded

Equitable Plan Services, Inc.

Third Party Administrators

EPS Providers
Online

Company Name:
Address:
City, State, Zip:
Other Locations?:
Nature of Business:
Effective Date: Proposal Due Date:
Current Carrier: How Long?
Employer Contributions: EE % Dep %
			Current Coverage		Proposed Coverage
Specific Maximum:			$		$
Specific Deductible:			$		$
Specific Contract:			12/1212/1515/12		12/1212/1515/12
			Paid		Paid
Specific to include:			MedRxOther		MedRxOther
Aggregate Lifetime Max:			$		$
Aggregate to include:			MedRxDent		MedRxDent
			VisSTDOther		VisSTDOther
Aggregate Contract:			12/1212/1515/12		12/1212/1515/12
			PaidOther		PaidOther
Include Monthly Aggregate Accommodation? YesNo
PPO Network:
UR Vendor:
Rx Vendor:
Current Rates:
	Specific:			Aggregate Factors:			Aggregate Premium:
Employee:		$		$		$
E/Spouse:		$		$
E/Child(ren):		$		$
Family:		$		$
Renewal Rates:

Employee:		$		$		$
E/Spouse:		$		$
E/Child(ren):		$		$
Family:		$		$

Any COBRA Participants? Yes No
If YES, how many? (denote COBRA participants on census)
Retirees Covered? Yes No (denote Retirees on census)
Any plan changes in the past 12 months? Yes No
If YES, denote summary of changes and effective dates
Any upcoming changes planned? Yes No
IF YES, denote summary of changes and effective dates

In Network Deductible:				Co-insurance: %
$Xper family
Out of Network Deductible:				Co-insurance: %
$Xper family
Office Visit Co-Pay in Net:				Out of Net:
$				$
		Generic		Preferred Brand		Non-Preferred / Single Source
Rx Co-Pay:		$		$		$

Please send Schedule of Benefits
Also required: Claims History: Minimum 2 years aggregate reports or monthly insured paid claims. The reports must include month-by-month paid claims and number of covered lives and the benefits included in the experience (preferably with Med, Dent, Rx separated). Details on all claims in the most recent 12 months in excess of 50% of the lowest requested specific deductible, to include diagnosis, prognosis, expense for current plan year and current status. Also provide details on any potentially catastrophic claims situation.

Census Must Include:

Name (optional)

Gender

DOB or Age

Employee

E/Spouse

E/1 Child

E/Children

Family

All Additional information can either be faxed to 405-755-1185 or emailed to quotes@epstpa.com.

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If you're looking for a company specializing in claims management, health benefits and administration to help lead your business into the next century, turn to the one that shaped the last decade -- Equitable Plan Services.