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0 <br />• <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 POS <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 />_$214.43_ employee $407.42_ employee plus child(ren) <br />$428.86 employee plus one $686.19 employee plus family <br />We propose the following for Prescription Drugs: <br />In Network, Generic $7 Brand Name $15 <br />Out of Network _In- Network Non - formulary $30 <br />PROPOSAL FORM <br />Business Name Brown & Brown, Inc. <br />Address <br />8000 Governors Sq. Blvd; 4400 <br />Miami Lakes FL 33016 <br />Signature <br />Name & Titlef,�. �,� +�i'�'S c�t_� ._� DateiJ <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 Phonq <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 />