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PROPOSAL FORM <br />CITY OF SUNNY ISLES BEACH <br />REQUEST FOR PROPOSAL #01 -11 -11 <br />GROUP HEALTH INSURANCE COVERAGE <br />We propose the following rate structure: <br />Group Health Insurance Program, consistent with the City specifications and details provided by <br />the bidder on attached sheets. <br />Cost per month, per employee: <br />employee <br />employee plus one <br />We propose the following for Prescription Drugs: <br />In Network, Generic Brand Name <br />Out of Network <br />PROPOSAL FORM <br />Business Name <br />Address <br />Signature <br />Name & Title <br />Phone # <br />employee plus two <br />employee plus three or more <br />Date <br />Fax # <br />Please provide the names and phone numbers of three references that use the Group Health <br />Insurance Plan that you have proposed. <br />Company Name Contact Person Phone <br />The City reserves the right to reject any and all bids. <br />-12— <br />Health Insurance Proposal 2001 <br />