Request for Quote
Administrative Contacts
W. Warren Barberg, CLU
307 S. Farwell St.
Eau Claire, WI 54701
Phone: (715)456-1930
Fax: (715)835-9229
E-mail: wwb@healthyxchange.com
Sales and Support
Sales
307 S. Farwell St.
Eau Claire, WI 54701
Phone: (715)835-5161
Fax: (715)835-9229
E-mail: hxc@healthyxchange.com
Form Instructions:
Contact Information:
Fill out the contact information as complete as
possible, and add any pertinent information in the "Your
Comments" area
Health Plan Information: Section A
1. Please fill out the number of "Single" Plans for active
employees.
2. Please fill out the number of "Limited Family" Plans
if you have such a group.
3. Please fill out the number of "Family Plans" for active
employees.
4. Please select the type of plan coverage, "Insured Plan"
if your company purchases Health Insurance from a third party; Select
"Self-Funded" if the company pays the claims and purchases
Stop-Loss Insurance; Select "Self-Insured" if the company
covers all costs associated with health Insurance, with the exception
of employee contributions.
Health Plan Information: Section B
Insured Plan:
Fill out this section only
if you chose an "Insured Plan" as your Health Benefit
type.
1. If you chose an "Insured Plan",insert the Total Current
Premium Paid.
2. If you chose an "Insured Plan please list the Insurance
Provider.
7. If you chose a Self-Funded Plan, input The total current cost
including:
--> Total claims actually paid
--> Total Stop-Loss Premium
--> Cost for Single, Limited Family and Family
--> Or average per member
--> Total Administration Expenses for TPA, Plan Administration,
Financial Services
--> Dollars Budgeted for Reserves
8. Input Employers cost of Health Plan.
9. Input Employees cost of Health Plan.
10. Fill in the date the plan renews.
11. Insert the estimated cost at renewal date.
12. Fill in the Employee Duductable.
13. Insert the Employee's Co-Pay.
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