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FINAL UNDERWRITING REQUIREMENTS

Before the Excess Loss Insurance Policy can be issued, the following must be received and reviewed by SLG Benefits:

• Signed Application for Excess Loss Insurance Policy
• Signed Schedule for Excess Loss Insurance Policy
• Signed Plan Sponsor Disclosure Statement
• Binder Premium including Premium & Enrollment Statement
• Plan Document
• Any other underwriting requirements or requested documentation

Final rates and factors are subject to possible revision based upon receipt and review of the following additional items as requested by your SLG Underwriter:

• The full census which should include a date of birth, sex and dependent status for all participants covered under the health plan as of the Policy effective date. Please be sure to include all COBRA participants, as well as potential COBRA beneficiaries. If retirees are to be covered, they must be clearly identified on the census. If the final enrollment is significantly different (+/-10%) from the census used to quote the group, please be aware that this may affect the quoted rates and/or factors.
   

• Claims experience for all included benefits up to the effective date, including month by month enrollment.
   

• Information on any Participant who has (1) incurred claims at 50% or more of the selected specific deductible; (2) had a Potentially Catastrophic Loss (PCL) diagnosis during the past 12 months; or (3) is reasonably expected to generate claims greater than 50% of the selected Specific Deductible. On any Participant that meets the above criteria, please submit the following to SLG Benefits: age, sex, employee or dependent status, diagnosis, prognosis, original date of onset, date last claim was received, total claims received to date and current employment status. The above information is required on all claims paid, processed and unpaid, pended or denied for any reason.
   

• Detailed information should also be provided to SLG Benefits on any disabled employee, dependent, COBRA participant or retiree. In addition to the standard information described above, we also require the following on these Participants: the date and nature of disability and the current medical/employment status (diagnosis, prognosis and expected date of return to work).
   

• The final executed Plan Document for the group. We must review and approve the plan document to verify that benefits correspond with those assumed when we prepared our quote. Any non-standard plan provisions or changes in benefits may result in adjustments to quoted rates and/or factors. Please be aware that our approval of the Plan Document shall not supersede any exclusions or provisions established in the Policy.
   

• Any other information that may be requested by the underwriter.

If any of the required information cannot be supplied for any reason in a timely manner, please contact your underwriter immediately to request additional time or guidance in satisfying the requirements to issue the Policy.