Group & Ministry Benefits Proposal Request
Small Businesses • Churches & Nonprofits
* Starred fields are required for California carriers to calculate accurate group rates. (Or attach an existing Excel census roster.)
Torrance Office: (310) 533-8877
1. Organization Profile & Coverage Goals
CA Corporate License #0I31557 • Strictly Confidential
CA
Organization Type:
Small Business
Church / Ministry
School / Academy
Nonprofit
*Lines to Compare:
Group Medical
Health Stipend (QSEHRA / HRA)
Dental
Vision
Group Life / Disability
Plan Types:
HMO
PPO
Kaiser
HSA / Level-Funded
2. Employee, Pastoral & Dependent Census
Have more than 10 lines? Simply attach your existing Excel roster or renewal bill.
Why Highlighted Columns Are Required: California small-group carriers calculate rates by each person's Role (Employee vs. Spouse/Child), Gender, Exact Date of Birth (MM/DD/YYYY), and Home ZIP Code. Please list each eligible employee and any family members they wish to cover on separate lines below:
| # | Employee or Family Member Name | *Relationship / Role (Check One Per Line) |
*Gender (Required) |
*Exact Date of Birth (MM / DD / YYYY) |
*Home ZIP (5-Digit ZIP) |
|---|---|---|---|---|---|
| 1 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 2 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 3 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 4 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 5 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 6 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 7 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 8 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 9 | Emp Spouse Child | M F | ___ / ___ / _____ | ||
| 10 | Emp Spouse Child | M F | ___ / ___ / _____ |
* Dependent children are eligible up to age 26.
Tip: For larger teams, feel free to email your current carrier invoice or spreadsheet instead of writing by hand.
3. Preferred South Bay Medical Groups & Organization Priorities
Helps us preserve your team's doctors while respecting your budget
Important Hospitals / Networks for Your Team:
Torrance Memorial (TMIPA)
Providence Little Co. of Mary
UCLA Health
Optum South Bay
Kaiser
Key Doctors to Verify or Main Goals for This Review (e.g., Lowering Renewal Increase, Adding Kaiser/PPO Choice, Pastoral Stipend):