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r� <br />U <br />U <br />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 -Dual Option <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 />_$271.60_ employee _$508.08_ employee plus child(ren) <br />_$604.01_ employee plus spouse—$793.36– 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 - Formulary <br />I' ' 6MMUMUMUM <br />Business Name Brown & Brown, Inc. <br />Address 8000 Governors Sq. Blvd; #400 <br />Miami L kes, FL 33016 <br />(a <br />Signature % �. <br />l Vic' 'C' t t rc I/,/(/ ICS <br />Name & Title t C S Date (; / <br />Phone # 305- 364 -7818 <br />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 Phone <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 />