Heritage Vision Plans

Phone: 1-888-322-0919
Fax: 313-863-5134
Email:corporate@heritagevisionplans.com

Heritage Vision Plans
440 E. Congress, Suite 300, Detroit, MI 48226

VISION PROPOSAL REQUEST
Heritage Vision Plans would be pleased to present a proposal that creates a valued, customized vision care program for your employees while minimizing the cost to your company. The following information is required for us to prepare a proposal. You may complete the form and submit it to us, or call us for a personal visit from one of our business development representatives.


Name of Company:
Address:
City:
State:
Zip:
Phone:	( ) -
Fax:	( ) -
E-mail:
Current Coverage
Current Vision Supplier:
Describe coverage:
No Current Vision:

Premium Contribution Structure
Employer Contribution:
Employee Contribution:

Additional materials required in electronic format. Please supply:	An aggregate list of the number of contracts by zip code for provider network development Benefit utilization for last two years Plan desired
Total # of eligible employees to be covered:
Single-Person coverage:
Two-Person coverage:
Family coverage:

Contact Information:
Contact information same as above:
Contact Name:
Company Name:
Address:
City:
State:
Zip:
Phone:	( ) -
Fax:	( ) -
E-mail:

Comments & Questions: