Request a Quote Requestor InformationName of Requestor* PhoneEmail* Group InformationName of Group* Contact Name* PhoneEmail* Number of Eligible EmployeesIs a census available?*YesNoIs the premium Voluntary or Employer Paid?*VoluntaryEmployerWhat percent of the premium is being paid by employer?*What percent of the eligible employees reside in Utah?*What is the effective date for this group? MM slash DD slash YYYY Does this group already have a vision plan offering?*YesNoPlease attach a copy of the current plan design and rates (if possible)Max. file size: 50 MB.Plan Design InformationWould you like a quote for plans:*With eye examWithout eye examProvide a quote for bothWhat level of frame benefit would you like: (check all they apply):* $110 Allowance $130 Allowance $160 Allowance $210 Allowance Other: Other level of frame benefit would you like:* Would you like information on Opticare’s Safety Eyewear program (manufacturing companies)?*YesNoOn a scale of 1-10, 10 being very interested, how would you rate this group’s interest in:Refractive Surgery Benefit (LASIK, ICL, PRK):Please enter a number from 1 to 10.Telehealth/Telemedicine ServicesPlease enter a number from 1 to 10.On-Site Vision Screenings for Health Fairs, etc.Please enter a number from 1 to 10.On-line Eyeglass OrderingPlease enter a number from 1 to 10.Agent/BrokerAgent/Broker Name of Agent/Broker* PhoneEmail* Name of Agency or General Agent (if applicable) PhoneEmail* Are you already appointed with Opticare Vision Services?*YesNoWould you like to set up a meeting (virtual or in-person) with an Opticare Vision Services representative?*YesNoPreferred type of meeting*VirtualIn-person 65731