Omega Benefit Group, LLC
Suite 400
1745 North Brown Road
Lawrenceville, GA 30043
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Information Request Form

(* Required fields)
 
Number of full time employees*:
Current TPA / insurance carrier*:
Renewal date of health insurance
/ benefit plan*:
 
Do you currently have
a broker / consultant?*
YES
 
(if Yes, please answer the following):
Broker / consultant name:
 
Who is your benefit plan decision maker?
Name:
Title:
 
Personal Information:
 
Contact Name*:
Organization*:
Address*:
City, State, Zip*:
E-mail*:
Phone*:
 



 
What do you anticipate will be the total cost change to your health care coverage at your next plan or policy anniversary (not counting offsets from plan design changes or increased employee deductions)?
Decrease Costs
Zero to 10% Increase
11% to 20% Increase
21% - or greater
 
Same question but for the following anniversary date?
Decrease Costs
Zero to 10% Increase
11% to 20% Increase
21% - or greater