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Thank you for your interest in EmployeeLife.com's B2Benefits Exchange. The B2Benefits Exchange is an electronic marketplace from which employers can design, request quotes, and purchase employee benefit coverages and services. If you would like to offer benefit coverages to medium to large sized employers, please complete the information below. This information will enable us to send your organization electronic Requests for Proposals, (RFPs), this can help to reduce your time entering data and checking for accuracy. Some of the questions ask for specific underwriting requirements. With this information we will be able to forward those proposals you wish to quote.

Your submission will serve as an indication of your willingness to receive RFPs from EmployeeLife's B2Benefits Exchange. If you have questions specific to this form or to the electronic exchange, please call Mike Ackerman at 1-610-254-9954 or email him at
For more information about the B2Benefits Exchange Program please contact Vineeta Hiranandani at
1-800-319-5633 x104 or email her at:

Thank You!

Required fields are in green.

INSURER OR ADMINISTRATOR INFORMATION
Name of Insurer or Administrator
Subsidiaries for which you will quote,
(I.e. New York company, non medical subsidiary.)


Sales Contact Name
Street Address1
Street Address2, Suite
City
State
Zip Code
Phone
Fax
Email


Rating Contact Name
Street Address1
Street Address2, Suite
City
State
Zip Code
Phone
Fax
Email
Email where RFP should go
(unless you make other arrangements RFP's will be emailed)


COVERAGES YOU WISH TO QUOTE(Check all that apply)
  Life/AD&D STD LTD
Number of Employees
100-500
500-2000
2000+
100-500
500-2000
2000+
100-500
500-2000
2000+
  401k AD&D Carve Out Travel Accident
Number of Employees
100-500
500-2000
2000+
100-500
500-2000
2000+
100-500
500-2000
2000+
  Voluntary Stop Loss Admin Services
Number of Employees
100-500
500-2000
2000+
100-500
500-2000
2000+
100-500
500-2000
2000+


Dental

  PPO DMO IND
Number of Employees
100-500
500-2000
2000+
100-500
500-2000
2000+
100-500
500-2000
2000+


Medical

  PPO POS HMO
Number of Employees
100-500
500-2000
2000+
100-500
500-2000
2000+
100-500
500-2000
2000+
  IND    
Number of Employees
100-500
500-2000
2000+
   



What version of Excel do you use?
2000 -
97 -
Version 5 or earlier -


What version of Word do you use?
2000 -
97 -
Version 5 or earlier -


What brand and version of browser do you use?
Netscape 4.0 or above -
Netscape 3 or lower -

Explorer 4.0 or above -
Explorer 3 or lower -



Enter unacceptable SIC codes
Enter unacceptable states for business
What other coverage would you like to quote in this manner?
Can employers enter eligibility and enrollment online?
- YES   - NO
Your Company's Web Site


PARENT COMPANY'S FINANCIAL RATINGS
Bests
Date
S&P
Date
Moodys
Date
Duff Phelps
Date
Weiss
Date


If you have any questions in regards to this form or electronic RFPs then please contact Mike Ackerman at 1-610-254-9954. If you have questions about EmployeeLife's B2Benefits Exchange, please call Vineeta Hiranandani at
1-800-319-5633 x104

EmployeeLife.com:
1290 Oakmead Parkway, Suite 318                                      
Sunnyvale, CA 94086
toll free: 1-800-319-5633
fax: 1-408-736-7831


For a printable version of this form click here.

 


 


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8/23/00


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