TheTaben Group

COBRA / HIPAA Administration Quick Quote Form

Note: This form is for Plan Sponsor use Only. Do NOT use this form to request individual COBRA or Retiree / Direct Billing premiums.

Please provide as much information as possible.
You may submit on line or fax the form to Chuck Tantillo at 913-649-7847.

Name of your organization
Your name and title
Phone #  
E-mail address
Current # of active plan participants 
Current # of COBRA participants

12 month history

COBRA Notices sent

New COBRA enrollments

Total on COBRA

Last month

2

3

4

5

6

7

8

9

10

11

12

Number of health plans/vendors offered?

Dental Plans?

Vision Plans?

Do you offer Flex Plans?

EAPs?

HRAs?

How many health plan rate tiers?

Dental Plan?

Vision Plan?

Of the health plans offered, how many have different rates?

 

  

How many locations/divisions/branches will report activity to Taben?

 
Do you offer subsidized rates, such as RIF, severance, or executive packages?    
How many locations/divisions/branches will Taben have to report to?