Get a Quote

Request for Proposals are made easy with our online quote submission process. Please fill out the information entirely and hit submit and the proposal request will be sent directly to Johnson Benefit Planning.

Please fill out the entire census form to receive the most accurate quote.

Final rates are determined by final enrollment. Changes in enrollment from the quote will result in rate adjustment

Group Information
Company Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Email*
Phone Number*
Request For Proposal
Effective/Renewal Date*
Contribution, employees*
Contribution, dependents*
Current Coverage
Current Carrier*
Current Plan Design*
- Ded
- OVC
- Coinsurance
- OOPM
Deductible*
Office Visit Copay*
Coinsurance*
Out of Pocket max*
Current EE Rate*
Current EES Rate*
Current EEF Rate*
Current EECH Rate*
Current EE Renewal Rate
Current EES Renewal Rate
Current EEF Renewal Rate
Current EECH Renewal Rate
Census Form

Current Employee Coverage Information

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Employee Name (Optional)	Birth Date	Gender (M/F)	Active / Waiving / Cobra / Declining / Ineligible / Probation (A/W/C/D/I/P)	Tobacco (Y/N)	Zip Code	Spouse (Y/N/DOB)	Children (#)	Child 1 DOB	Child 2 DOB	Child 3 DOB	Child 4 DOB	Child 5 DOB	Child 6 DOB	Child 7 DOB	Child 8 DOB	Child 9 DOB	Child 10 DOB

Comments
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Get a Quote

Group Information

Request For Proposal

Current Coverage

Census Form

Locations/Contact

Central Oregon Office

West Linn Office

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