Worksite Benefit Plans, Inc.

One Administrator for all your benefit needs.

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(HRA) 105 Administration

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COBRA Proposal Request

Click "here" to return to the Proposal Request Page.

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Proposal Request:

Complete and click send to request a proposal for your client.

To view a schedule of fee's click "here".

Fee adjustments to provide broker compensation must be indicated when a proposal is first requested and are limited to items listed on the request form. To read more about broker fee adjustments click "here".


COBRA Proposal Request for: Employer Name
Agency/Brokerage Name
Agent Name
Agent Address
City & State
Zip Code
Agent Phone #() -
Agent FAX #() -
Agent E-mail
Method of Delievery (Mail, FAX, E-mail)
Setup Fee Adjustment (Yes/No)
Setup Fee Adjustment $ *
Comments
 
 

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Remember, click send above when you have completed the form.


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