Get a Quote | Self Fund Health

Essential Information

Tell us about the employer group.

Employer Group Name *

Employer Group Address *

Main Contact First Name *

Main Contact Last Name *

Main Contact Email *

Effective Date *

Proposal Due Date

First time quoting this group with Self Fund Health? *

Yes No

SIC Code *

Total Enrolled Employees *

Total Enrolled Members *

Total Eligible Employees *

Current Carrier (or Current TPA) *

Is Run-in Needed? *

Yes No

Preferred DPC (if any)

Broker / Submitter

Broker and submitter details.

Broker Agency *

Broker First Name *

Broker Last Name *

Broker Email *

First time quoting with Self Fund Health? *

Yes No

Broker Commission PEPM *

Specify Commission

Submitter Email *

If different from broker email

Agency Account Manager

Who should we coordinate with on the account?

First Name *

Last Name *

Email *

Essential Files

Upload required documents for quoting.

Census *

Click to upload or drag and drop

Current Rates *

Click to upload or drag and drop

Current Plan SBC(s)

Click to upload or drag and drop

Renewal Rates (if available)

Click to upload or drag and drop

If renewal rates aren't available, when will they be?

Additional Reporting

Help us understand the group's claims history.

Current Plan Agreement *

Fully Insured Self-Funded Level Funded

For Currently Fully Insured Groups, please provide (current plan year + up to 2 prior years):

MLR reports, high-cost claimant reports
Rx provider-specific prescription reports
Medicare/Medicaid enrollment data
Large case management historical data for prognosis, outcomes and treatment lengths (if available)

Attach Additional Reporting

Click to upload or drag and drop (multiple files OK)

Plan Design

Select your preferred plan options. You can request up to two designs.

Requested Contract Term *

12/12 12/15 24/12

Requested Contract Type *

Spec & Agg Level Funded

Requested Plan Design 1

Requested Plan Design 2

Plan Design 1 Specific Deductible (if applicable)

Plan Design 2 Specific Deductible (if applicable)

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Thank you for submitting a request

Our team will reach out to you as your submission is processed.