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Insurance Providers

Phone: 1-888-322-0919
Fax: 313-863-7710
Email:corporate@HeritageOptical.com

Heritage Optical
19010 Livernois Avenue, Detroit, MI 48221

VISION PROPOSAL REQUEST
Heritage Optical 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:


 

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