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< Return GASB 74 / 75 Valuations
Quote Information Request		  
For each Valuation required (i.e., Annual Required Contribution Development)
 
    *Entity's Name (Employer, Union, Fund)
    *Contact First Name
    *Contact Last Name
    *Contact Email Address
    *Contact Phone Number
         
   
    *Which fiscal years will be covered by the valuation we propose to prepare?
       
    Participant Data  
    Number of Covered Employees
    Number of Covered Retirees
         
    *Type of Insured Arrangement:
   
                     
    Benefits Provided (check all that apply)            
                 
      Medical       RX  
        Pre - Medicare Eligible Retiree     Pre - Medicare Eligible Retiree
        Post - Medicare Eligible Retiree     Post - Medicare Eligible Retiree
        Pre - Medicare Eligible Spouse     Pre - Medicare Eligible Spouse
        Post - Medicare Eligible Spouse     Post - Medicare Eligible Spouse
                     
      Dental       Vision  
        Pre - Medicare Eligible Retiree     Pre - Medicare Eligible Retiree
        Post - Medicare Eligible Retiree     Post - Medicare Eligible Retiree
        Pre - Medicare Eligible Spouse     Pre - Medicare Eligible Spouse
        Post - Medicare Eligible Spouse     Post - Medicare Eligible Spouse
                     
      Life            
        Pre - Medicare Eligible Retiree        
        Post - Medicare Eligible Retiree        
                     
         
*Required Information
  
       
 
 
               
 
 
     
 
 
     
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