Request a Mini-Med Proposal

Agent Data
First Name:
Last Name:
Phone #:
Email:
Broker License No:
License State:
Attach a Copy of License:		(Attach File )
Proposal Request
Group Name:
Group Legal Location Address:
State:
Situs Zipcode:
Plans Option Selected: (Choose 3 Plans Only)		Med-Choice Plus Value Care Value Care Plus Preferred Care Plus Premier Care
Number of Eligible Employees:
Requested Effective Date:
Request a Geo Access Report:		Yes No
Geo Report Requires a Census:		(Attach File )

The OptiMed program is not available in the State of Washington and State of Montana. Please check with your UGP sales representative to confirm that OptiMed is available in the state or states in which you may have an interest in offering OptiMed.