Request a Quote

To learn about your options and cost to participate in our food employers Health Trust, simply complete the information below.

THREE WAYS TO SUBMIT YOUR REQUEST FOR A QUOTE:

Complete this survey on-line
Print this survey and fax it to us
Print this survey and mail it to us

We will return your rate quote within two business days of receipt.

Here is the information we need to prepare your quote:

Note: All contact information is required.

Contact Information

Business Name
Contact Name
Number of employees in Oregon
Number of employees in Washington
Total number of employees
Mailing Address
City	State Zip
Phone
Fax
Email

Benefit Options
Check as many options as you like and we will provide a cost for each.
(Refer to the Benefits Summary for details concerning these options.)
Note: Cost of benefits is reduced when you select options where choice of medical provider is limited.

Select BENEFIT OPTIONS you would like quoted (see benefit descriptions)
	BASIC - $30 office visit co-pay Use doctors from network (PPO)	$1500/$3000 Deductible - Plan pays 80% in network
	PRIMARY - $30 office visit co-pay Use doctors from network (PPO)	$1000/$2000 Deductible - Plan pays 80% in network
	TRADITIONAL - $25 office visit co-pay Use doctors from network (PPO)	$750/$1500 Deductible - Plan pays 80% in network
	STANDARD - $20 office visit co-pay Use doctors from network (PPO)	$500/$1000 Deductible - Plan pays 80%
	PREMIER - $20 office visit co-pay Use doctors from network (PPO)	$250/$500 Deductible - Plan pays 80%

NOTE: All plans include vision, short-term disability, and life insurance benefits.

Other Plans
Would you like more information on any of these additional enhancements?

Increased Lifetime Maximum Health Benefit from $1 million to $2 Million
High Deductible Plans that can reduce annual costs (partially self-insured for over 50 employees)
Dental Coverage
125 Plan (Flexible Benefits)
On-job coverage for Owners (replaces work comp)

Participation
Tell us about the employees you wish to insure:
Note: To qualify, employees must work at least 17.5 hours per week with a minimum of 2 employees participating.

How many employees want coverage only for themselves?
How many would like coverage for themselves and spouse?
How many would like full family coverage?
How many would like coverage for employee (no spouse) and children only?

WESTERN GROCERS EMPLOYEE BENEFITS TRUST

Western Benefits Inc., Administrator
14835 S.E. 82nd Drive, Suite 201, Clackamas, OR 97015
800-777-3603
503-968-2360
fax 503-968-2817
info@westerngrocerstrust.com

printable version