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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: Aetna USAccess 4 Stand Alone <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 />$259.90_ employee _$486.20_ employee plus child(ren) <br />$578.00 employee plus spouse—$759.20_ employee plus three or more <br />We propose the following for Prescription Drugs: <br />In Network, Generic $10 Brand Name $15 <br />• Out of Network $30 In network Non- Formualy_ <br />PROPOSAL FORM <br />Business Name _Brown & Brown, Inc. <br />Address 8000 Governors Sq. Blvd; #400 <br />Miami Lakes'JL 330,16 <br />Signature <br />Name & Title Date --a %/6 (� / <br />Phone # 305- 364 -7818 Fax #305-822-5687 <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 Phonq <br />• The City reserves the right to reject any and all bids. <br />-12– <br />Rfp No. 01 -11 -01 Grp Health Ins. Bid Package <br />