| |
Official name of the employer |
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Location of the group (City,
State, Zip) |
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Desired effective date of
coverage |
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Quote due date |
| |
Specific deductible (current and
proposed) |
| |
Contract type (current and
proposed) |
| |
Commission level requested |
| |
Current census (including year
of birth or age, sex and type of coverage- if Cobra, Retiree or
Disabled please designate accordingly) |
| |
If the employer has multiple
locations, include the number of employees in each
location with corresponding zip code. |
| |
Nature of business and/or SIC
code |
| |
Schedule of current benefits and
proposed benefits, if different. (Note which coverages are to be
included under the specific and aggregate contracts.) |
| |
Monthly paid claims and
enrollment (Month by month aggregate report for the most recent 24
month minimum) |
| |
Current and/or renewal rates
(whether self-funded or fully insured) |
| |
If fully insured with no paid
claims experience, provide current and renewal fully insured rates
on groups up to 250 lives. |
| |
Shock claims in excess of 50% of
the current deductible and any serious ongoing condition including
diagnosis/prognosis |
| |
PPO network and UR facility
being implemented (if multiple networks, please specify by
location.) |
| |
Please note the current PPO
network if different than the proposed. |
| |
Ancillary coverages requested
(i.e. Aggregate Accommodation, Terminal Liability or Split-Funded
Specific) |
