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COBRA Proposal Request Form

Please complete the form below. It generally takes three to five business days for you to receive a proposal via e-mail. On occasion, we may have follow-up questions. We will submit these questions to you via e-mail. You may check on the status of your proposal by clicking any "Contact Us" button on this site.

If you need a non-standard proposal, a hardcopy proposal, or if there is a formal Request For Proposal (RFP), please complete the form, allow two weeks for processing in the due date field, and indicate in the special requirements in the Comment Section at the bottom of the form. Please send the RFP to the BenefitsWorkshop at the following address, via expedited mail, if the proposal is due in less than two weeks.

BenefitsWorkshop
P. O. Box 56828
Jacksonville, FL 32241
(904) 631-2629

Please enter the information below and press the "Submit" button. All fields marked with an asterisk (*) are required.


INFORMATION ABOUT THE EMPLOYER

*Name of Employer:

Address:


*City:

*State:

Zip Code:

*Number of Eligible Employees:

*Nature of Business:

*Type of Organization:


INFORMATION ABOUT YOUR CURRENT COBRA ADMINISTRATION PROCESS

*How is COBRA administration currently handled?

*Number of Current COBRA participants:

*Annual Turnover (estimated percentage):

Number of COBRA events annually (if known):


INFORMATION ABOUT YOU

*Your Name:

*Your Company (if different than above, or "N/A"):

*Title:

*Phone:

*E-mail:

*Date needed - MM/DD/YYYY (please allow at least 3 days, 5 is preferable):

*You are the:

Coupon Code (if any):

Comments:





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