Alliance of Schools for Cooperative Insurance Programs

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- Reopening Schools Planner
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Insurance for Schools
Risk Services
Training
Forms & Tools
Contact

Health Benefits

Home > Insurance for Schools > Health Benefits > Request Health Benefits Quote

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Request Health Benefits Quote

Download the PDF version of this form
Download the Census Template

Need Quote For (check all that apply):
- Medical
- Dental
- Vision
- Life
- Disability
- Social Security Alternative Plan
A Benefits Specialist will provide you with the available plan options for each line of coverage upon review of this application. For questions, call (562) 404-8029 or email us at benefits@ascip.org.
PART 1 - CURRENT SCHOOL DISTRICT INFORMATION
District Name
District Contact Name
Phone
Fax
Address
Street AddressCityStateZIP Code
Email
Current Broker Agency (if any)
Broker Contact Name
Broker Phone
Broker Email
PART 2 - CURRENT HEALTH & WELFARE PLAN INFORMATION
Total Number of Benefits-Eligible Employees
Number of Active Full-Time Employees
Number of Active Employees Waiving Benefits
Current Effective Date
- October 1
- January 1
- Other
Date
Does the district cover Board Members
- Yes
- No
Does the District administer Health Benefits for Retirees?
- Yes
- No
Does the District prefer retiree rates separate from the active rate?
- Yes
- No
Please provide a brief description of which retirees the districts pays for
Describe the current participation requirements for the plans requested
(who must enroll, cash in lieu offerings, voluntary offerings, etc.)
PART 3 - SUBMIT THE FOLLOWING MATERIALS TO ASCIP
- Completed ASCIP District RFP Workbook (current census, rates, contributions) REQUIRED.
- Monthly enrollment and claims experience by plan (medical, dental & vision) for the most recently available 12 month period (24 months preferred).
- List of participants currently on disability, including diagnosis, prognosis, age and current medical plan. (no names or identifiers)
- Plan summaries for all current lines of coverage.
- Current Billing Statement or List Bill
- Description of all employee and dependent contributions
- Other
Other

Email the Workbook to: benefits@ascip.org.
For questions, call (562) 404-8029 or email us at benefits@ascip.org.

Submission of this form authorizes ASCIP to share information with service providers and carriers to obtain quotes on the District’s behalf.

Please allow a minimum of 4 weeks for quote submissions.

Contact Info

Main Office/Southern California Claims Handling:
16550 Bloomfield Avenue
Cerritos, CA 90703

Northern California Claims Handling:
1531 "I" Street, Suite 100
Sacramento, CA 95814

Email: ascip_info@ascip.org
Phone: (562) 404-8029
Fax: (562) 404-8038
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