There is no obligation or cost for having us prepare a proposal for your firm ...

How To Request A Proposal:

•    Fill in the form below.

•    If your company is in NY State and includes fewer than 50 employees the information on the form below will be sufficient for a medical plan quote.

•    If your company is outside of NY State, employs 50 or more employees, or if you desire bids for other than medical insurance, a detailed census will be needed, in addition to completing the form below. This can be emailed in Excel format to: sneski@briarclifffinancialgroup.com , or fax it to 914-762-9353.  For medical or dental plans, the census must include employee gender, date of birth, family status, and home zip code. For group life we need to know the amount of insurance each employee is to receive. For Long or Short Term Disability Income plans, we will need the job description and compensation for each employee.

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Information Request Form

Select the items that apply, and then let us know how to contact you.

Email the proposal
Email the application and enrollment forms
Have a benefit consultant contact me

CONTACT INFORMATION:

Name
Title
Company
Nature Of Business:
Address
City
State	NY NJ CT    ****Please note that we only work with clients in NY, NJ or CT.
Zip
E-mail
Phone
Fax

CENSUS INFORMATION:

Number of Employees, Single:
Employee + Spouse:
Employee + Child(ren):
Employee + Spouse + Child(ren):

PLAN(S) REQUESTED:

Type of Plan Requested:	Medical:	Dental:	Long Term Disability:	Short Term Disability:
	Vision  Care:	401(k)	Other (please specify):

MEDICAL PLAN(S) REQUESTED:

Medical Plan Options (check all that apply)	PPO:	Non-Gated POS:	POS:	EPO:	HMO:
If you don't know what type of plan you want, check this box:    A consultant will call you to discuss your needs.
Plan Co-Pay:	$5	$10	$15	$20	Highest Available
Non-Network Deductible:	80% of $5,000	80% of $10,000	70% of $5,000	70% of 10,000	Least Expensive
U.C.R.	70th Percentile	80th Percentile	90th Percentile	Usual, Customary and Reasonable percentile determines the level of allowed claims on a NON-NETWORK basis. Not all carriers give a choice of UCR.
Drug Card	Richest Available Three Tier	Medium Level Three Tier	Least Expensive w/o Calendar Year Deductible Three Tier	Least Expensive w/ Calendar Year Deductible Three Tier	None
Carriers Requested:
		Oxford Health Plans
Tell us a little bit about your design objectives for this plan:
Current Carrier:
Renewal Date:

 

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Copyright © 2002 Briarcliff Financial Group, Inc.
Last modified: 07/04/02