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Please provide us with as much information as possible to ensure we provide you with the most cost effective, comprehensive quote.

Please keep in mind, we often customize vision plans to meet the specific needs of our customers. If there is something specific you would like to see with this group, please add it in "additional information regarding this quote" so we may better meet your needs.

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Group Information

Proposal Information

Does this client currently offer a vision plan other than Opticare of Utah?	Yes No
Are copies of the current vision plan design available?	Yes No
Formal RFP Required?	Yes No
*Date of proposal deadline (MM/DD/YYYY):
*Email Address:
Additional information regarding this quote:

Effective Date

Term of Contract - 12 mo., 24mo., or other:

Agent Information

*Agent Name:
Agency:
*Phone Number:
Additional Phone Number:
*Email Address:

Do you or your agency need to get appointed to Opticare of Utah?
Download Appointment Packet (PDF)

*Group Name:
*Number of eligible employees:
Number of total employees:
Are there other specific eligibility requirements?	Yes No
If yes, please describe:
Voluntary or Employer Contribution
*What percentage:
Are there other details regarding employer contribution?	Yes No
If yes, please describe:
Desired Plan Design(s):	Group Vision 10-120 C Group Vision 120 C Group Vision 10-70 C Group Vision 70 C

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Group Information

Proposal Information

Effective Date

Agent Information

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