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r_1 <br />LJ <br />LJ <br />• <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: Humana HMO Opt. 1 <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 />_$193.01_ employee _$366.71_ employee plus child(ren) <br />_$386.01_ employee plus spouse—$617.63– employee plus family <br />We propose the following for Prescription Drugs: <br />In Network, Generic $10 Brand Name $20 <br />Out of Network $35 In network Non - Formulary <br />PROPOSAL FORM <br />Business Name Brown & Brown, Inc. <br />Address 8000 Governors Sq. Blvd; #400 <br />Miami Lakes, FL 33016 <br />Signature 4 / ✓ l A " <br />Name & Title r ,�� �:°. A or.5 Date Z <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 />Name Contact Person Phone <br />S <br />The City reserves the right to reject any and all bids. <br />RFp No. 01 -11 -01 Grp Health Ins. Bid Package <br />-12— <br />