Proposal Request Form

To get started, please provide the following information:

Agency Name
Agency Address
Street City State Zip
Agency Contact
Title
Phone
Email
Prospect Name
Prospect Address
Street City State Zip
Effective Date
Date Format: MM slash DD slash YYYY
Notes (Effective Date)
Approx. Number EEs
Notes (Approx. Number EEs)
Primary Services
- Advocacy/Benefits App
- Behavioral Health
- Telemedicine
- Rx
Branding
- Agency
- Prospect
Branding (Agency or Prospect)
Please forward a high-resolution logo:
What pricing should be displayed in the proposal?
- List at Net Cost*
- Show Prospect Rate*
Enter Prospect Rate (if applicable)
NOTE: We offer three types of billing options as listed below. You will select the appropriate option when submitting the Implementation Form.
- Agency Master Bill (Billed at Net Cost – No Billing Fee)
- Third Party Billing (TPA, Etc. – Billed at: Net Cost – No Billing Fee)
- Direct Group Billing (Billed at Net Cost – plus Direct Billing Fee*)
Direct Billing is a service provided as a convenience to our Clients. There is an administrative fee of $0.25 pepm per each group with a $50.00 cap and a $10.00 minimum. Direct Billing Fees are retained from rates marked up to the Group. In cases where there is no mark up (Groups are billed at Net Cost), Benezon will invoice the agency the Direct Billing Fee.
Special Instructions