Direct/Retiree Billing 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.

Thank you for your interest in our Direct Billing services. In order to prepare a proposal with an estimated cost illustration,
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 Retiree plan participants:		# of new retirees last 12 months
Number of health plans offered to Retirees (HMOs, PPOs, POS, etc)?		Dental plans?	Vision plans?
Of the different medical plans offered, how many have different rates?		What is your tier structure?
Do you offer automatic bank account withdrawal?		Would you like Taben to offer ACH service to your retirees?
Do you provide coverage until age 65?		Do you provide Lifetime coverage?
Do you have subsidized rates (ie: early retirement offers)?		Do you have a separate Rx vendor you would like notified?
How many locations/divisions/branches will report activity to Taben?
Do you allow a spouse to remain on the plan in the event of retiree's entitlement to Medicare, death, or decision to drop their benefits?