First Name *

Last Name *

Email *

Phone

I am a(n) * Broker Consultant Administrator Attorney Employer Other

Organization Name *

Organization State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Medical Plan? * Yes No Does this quote request include an Implementation Audit on a Medical plan?

Plan Effective Date * Date that new Medical plan is to go live.

# of Plans * Total # of unique Medical benefit plans being offered to employees.

Administrator TPA managing the Medical benefits on behalf of the plan.

Concerns Description of concerns for BMI to consider while conducting the audit on behalf of the plan.

Prescription * Yes No Does this quote request include an Implementation Audit on a Prescription (Rx) plan?

Plan Effective Date * Date that new Rx plan is to go live.

# of Plans * Total # of unique Rx benefit plans being offered to employees.

Pharmacy Benefit Manager PBM managing the Rx benefits on behalf of the plan.

Concerns Description of concerns for BMI to consider while conducting the audit on behalf of the plan.

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