Get a Quote for Smarter, Simpler, More Affordable Care

Fill out our form in its entirety in order to reduce any delays in your proposal. For questions, please reach out to us at info@hphealthplan.com

Minimum Life Count For A Quote is 25 Enrolled Employee Lives. Using our provided CENSUS TEMPLATE will help avoid unnecessary delays.

CENSUS TEMPLATE.CSV

Employer Information

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Company/Organization Name (Legal Name) *

Company Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Standard Industry Code (SIC)

Company Tax ID #

Number of Employees (Enrolled in Medical Plan) *

Primary Contact Name *

First

Last

Please list person submitting the quote and who should receive the quote upon completion.

Primary Contact Email *

Please list email of person submitting the quote and who should receive the quote upon completion.

Primary Contact Phone

Primary Contact Title/Entity *

Please list name of organization primary contact is associated with.

What best describes your current health plan? *— Select Choice —Fully InsuredLevel FundedSelf Funded with Stop Loss

What Month Does Your Plan Renew *— Select Choice —JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Quote Deadline

Which HPHP Plans are you requesting a quote for? *

• Plan 1
• Plan 2
• Plan 3
• Plan 4
• Plan 5 (HSA)
• Plan 6 (HSA)

Plans 1-4 are “Copay” options. Plans 5-6 are “HDHP/HSA” options. You can select up to three plans.

Requested Stop Loss Contract *

• 12/12
• 12/15
• 12/18
• 12/24
• 15/12
• 18/12
• 24/12

Select the stop loss contract terms. You may choose up to three options for illustrations.

Specific Deductible Threshhold

Selected Value: 25000

Please enter the Specific Deductible level you are requesting.

Are you requesting any of the following features in stop loss quote? *

• Terminal Liability Option (TLO)
• Spec Advance
• Agg Accommodation
• Rate Cap
• No New Laser
• Other
• None

Can select more than one option

Information Regarding High Cost Claimants

Include as much detail as possible on any/all high-cost claimants. This will help ensure most competitive rates.

Dependent Census *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Please complete census information for all covered members, including spouses and dependent children and upload here.

Summary of Benefits & Coverage (SBC)

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload your current benefit summaries here that outline all coverages, ie: deductibles, copays, benefits, etc.

Current & Renewal Rates

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Please upload any current premium rates, invoices, and renewal rates for medical plan here. If rates are not provided, HPHP quotes will not be “firm”.

Claims Data

Drag & Drop Files, Choose Files to Upload

Please upload any claims reporting you can obtain: aggregate report, high cost claimant report, top drugs by spend, etc. Claims history is how we underwrite our HPHP quotes, and is extremely important. Reach out to HPHP if you need assistance obtaining claims reporting. If Fully-Insured in Texas, upload the HB2015 Tier One and Tier Two report.

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