First Name *

Last Name *

Email *

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How did you hear about us? Benefitpitch BMI Email Continuing Education Conference/Event LinkedIn Shortlister Web Search Word of Mouth Other

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

Organization Name *

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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 (Rx) Plan? * 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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