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L' <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: BCBS HMO <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 />_$238.81 employee $469.29_ employee plus child(ren) <br />$522.13 employee plus spouse $752.61 employee plus family <br />We propose the following for Prescription Drugs: <br />In Network, Generic $10 Brand Name $25 <br />Out of Network _In- Network Non - formulary $40 <br />PROPOSAL FORM <br />Business Name —Brown & Brown, Inc. <br />Address 8000 Governors Sq. Blvd; #400 <br />Miami.La s, FL 3%3016 <br />71 Signature <br />Name & Title "XF . ; %may 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 -I 1 -0 1 Grp Health Ins. Bid Package <br />