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I. Plan Sponsor Information*
Contact Name
Email Address
Company Name
Type of Entity
Address
City
State
Zip Code
Phone Number
II. General Plan Information
1. Plan Name(The "*Plan*")
2. Plan Year
3. Total Number of Active Employees with Drug Coverage under the Plan
4. Total Number of Retirees with Drug Coverage under the Plan ("*Covered Retirees")
(A) Number of Covered Retirees who are age 65 or older (as of 1/1/2006)*
(B) Number of Covered Retirees who are under age 65 (as of 1/1/2006)
5. Total number of Covered Spouses of Covered Retirees, if known
(A) Number of covered spouses who are age 65 or older (as of 1/1/2006)
(B) Number of covered spouses who are under age 65 (as of 1/1/2006)
6. Is your retiree plan self-funded or fully insured?*
Click here if you would like to download a blank quote request form which can be printed, completed on paper and faxed to Part D Advisors.

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Contact

Part D Advisors, Inc.

47799 Halyard, Suite B

Plymouth, MI 48170

888-447-2783

734-459-9733 (fax)

info@partdadvisors.com

Request for Quote

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