RFP Intake Portal

Start or resume a case

If the broker/consultant already emailed a completed RFP Questionnaire, ask them for the Case ID and enter it below. Otherwise, create a new case here.

Have a Case ID?

Or create a new case

Every field below matches the RFP Questionnaire PDF (CCMS 2026-08), page for page, so this form can fully replace a mailed-in PDF. Supporting Documentation (page 3) isn't repeated here — that's what the drag-and-drop zones on the next screen are for.

Requested Response Date

Requested Output *

Illustration Indication Proposal

Data Supplier: Broker / Consultant

Entity Name *

Entity Type *

Contact Name *

Contact Email *

Contact Phone

Relationship to Insured *

Deliver Output To *

TPA Attestation (if Primary Relationship)

Insured Information

Legal Name *

Street Address

City

State *

Zip *

Insured Profile

Nature of Business

SIC

Participating EEs *

Coverage Detail — Current / To Be Proposed

Effective Date (Current)

Effective Date (Proposed) *

Broker of Record *

Funding Type (Current) *

Funding Type (Proposed)

Incurred / Run-out (Current) †

Incurred / Run-out (Proposed)

Run-In / Incurred (Current) †

Run-In / Incurred (Proposed)

† At least one of the two rows above is required (Incurred/Run-out OR Run-In/Incurred).

Specific Ded. (Current)

Aggregate Coverage (Current)

Aggregate Coverage (Proposed)

Agg Spec Ded. (Current)

Agg Spec Ded. (Proposed)

Coverage Options

Aggregate Accommodation requested?

COBRA EE Coverage included?

Retiree Coverage included?

Ancillary Organ Transplant Policy in Place?

Health Plan Service Provider Stack

Current provider in place today, and desired provider for this submission.

Requested Coverage Details

Deductible Option 1

Deductible Option 2

Deductible Option 3

Desired Renewal Date *

Policy Term *

Policy Duration *

Desired Tiers

Special Requests

Certification

By submitting, the Data Supplier certifies the information is accurate and complete to the best of their knowledge.

Name *

Date *

Title

Drop supporting files for this case

Each zone below is owned by a named Claude Agent. Files route to that agent automatically on drop.