An affiliate of Vision Plan of America
(213) 616-0640

Request For Quote

Name of Prospect
Location Zip Code:
Nature of Business
Are you currently the Broker? Yes No
Your Phone *
Your Name *
Does your prospect currently have Vision coverage? Yes No

If Yes:

 
What is/are the current plan(s) (please include benefit summaries):
Prepaid:

Indemnity:
Current Rates:
Prepaid:
Single:
Couple:
Family: 		Indemnity:
Single:
Couple:
Family:
Renewal Rates:
Prepaid:
Single:
Couple:
Family: 		Indemnity:
Single:
Couple:
Family:

Total number of employees

Total number of eligible employees
Total number of participating employees (Please include census)
What percentage of the Employee Premiums is the Employer Contributing? %
What percentage of the Dependent Premiums is the Employer Contributing? %
Requested Coverage: Voluntary Employer Paid
Prepaid
 Benefit Design; Deductible (if any):
Indemnity
 Benefit Design; Deductible (if any):
Requested Effective Date
Broker Name:
Broker Fax:

* Required Fields