Proposal Request Form To get started, please provide the following information: Agency NameAgency Address Street City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Agency ContactTitlePhoneEmail Prospect NameProspect Address Street City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Effective Date Date Format: MM slash DD slash YYYY Notes (Effective Date)Approx. Number EEsNotes (Approx. Number EEs)Primary Services Advocacy/Benefits App Behavioral Health Telemedicine Rx BrandingAgencyProspectBranding (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