Actuarial Quote Request Form

Municipality:
Name
Address
City
State
Zip
Contact Person:
Title	Select one Mr. Ms. Mrs. Dr.
Name
Position	Select one Attorney Board of Directors Member Clerk Elected Official Human Resources Manager Supervisor Treasurer Other
Phone
E-mail
FAX
Plan 1
Type of plan	Medical Dental Hearing Optical Life Long-term Care Prescription Reimbursement Other
Premium-based  Self-funded
Total active employees   Total Retirees
This is a collectively bargained plan.
Plan 2
Type of plan	Medical Dental Hearing Optical Life Long-term Care Prescription Reimbursement Other
Premium-based  Self-funded
Total active employees   Total Retirees
This is a collectively bargained plan.
Plan 3
Type of plan	Medical Dental Hearing Optical Life Long-term Care Prescription Reimbursement Other
Premium-based  Self-funded
Total active employees   Total Retirees
This is a collectively bargained plan.
Plan 4
Type of plan	Medical Dental Hearing Optical Life Long-term Care Prescription Reimbursement Other
Premium-based  Self-funded
Total active employees   Total Retirees
This is a collectively bargained plan.
Comments/Questions
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