Request for proposal: EverydayCARE Hospitalization 20+eligible employees

$395 per Employee/Month

Referring Agent *

Business Name *

Estimated Start Date * 🛈 +

Business Address *

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Build Your Group Plan

iEverydayCare with Hospitalization

Employee ONLY

Number of Employee-Only Plans
($395/membership) *

# Delta Dental Plans 🛈

# VSP Vision Plans 🛈

# United Healthcare
Critical Illness 🛈

# United Healthcare
Accident Plans 🛈

United Healthcare
Term Life Insurance 🛈

Employee +Spouse

Number of Employee +
Spouse Plans ($785/membership) *

# Delta Dental Plans 🛈

# VSP VisionPlans 🛈

# United Healthcare
Critical Illness 🛈

# United Healthcare
Accident Plans 🛈

# United Healthcare
Term Life 🛈

Employee +Child(ren)

Number of Employee
+Child(ren) plans ($815/mem) *

# Delta Dental Plans 🛈

# VSP Vision Plans 🛈

# United Healthcare
Critical Illness 🛈

# United Healthcare
Accident Plans 🛈

# United Healthcare
Term Life Insurance 🛈

Employee +Family

Number of Employee +
Family ($1145/membership) *

# Delta Dental Plans 🛈

# VSP Vision Plans 🛈

# United Healthcare
Critical Illness 🛈

# United Healthcare
Accident Plans 🛈

# United Healthcare
Term Life Insurance 🛈

Employer Contribution

To comply with the ACA, and satisfy Penalty A (MEC) & Penalty B (MVP), a minimum contribution must be chosen.

Minimum Contribution: Full Contribution:

Employer Employee Employer Employee

Employee $195 $200 $395 $ 0

Employee +Spouse $195 $590 $395 $390

Employee +Child(ren) $195 $625 $395 $420

Employee +Family $195 $950 $395 $750

Employer Minimum Contribution *

Pre-existing conditions covered

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I certify that I am an authorized representative of the Company indicated above and that I have the authority to request a quote on the Company's behalf. The company understands that this authorization will remain in effect until it is canceled in writing and agrees to notify Freedom Benefits Group at least 15 days in advance of any changes in the account information or termination of this authorization.