Forms Checklist

• Company name, address (including zip code)
  • Subsidiaries, address (including zip code)
• SIC code and/or nature of business
• Current and requested effective date of coverage
• TPA/Broker/Consultant/Producer with contact information and requested commission level
• Current coverage type (fully insured; self-funded; etc.) and carrier name
• Current and/or renewal rates, terms (contract type; lasers; etc.), commission, and factors when
• applicable
• Current TPA and stop loss carrier
• PPO network(s) by location/zip code to include employee counts by PPO network
• Utilization Review vendor
• Large Case Management vendor
• Participation percentage
• Requested coverage: Aggregate and/or Specific Deductible level(s)
• Coverage type: Medical, Prescription Drugs, Dental, Vision, STD
• Requested contract type(s): 12/12; 15/12; 12/15; etc.
• Current electronic census (for each location/subsidiary): including single and family count, gender, age or year of birth, zip code, active, retired, disabled, and COBRA participants
  • When being asked to cover retirees, the census should identify retirees under and over age 65 and show whether the group’s plan or Medicare is primary for retirees and their dependents
• Groups that are currently self-funded require at least the most recent 36 months of month-by-month paid claims and enrollment by coverage type (Medical, RX, Dental, etc.)
• Requested Schedule of Benefits including but not limited to:
  • Lifetime and/or Benefit Year Maximum
  • Deductibles
  • Coinsurance
  • Out of Pocket Maximum
  • Accident Benefit
  • Mental & Nervous
  • Co-Pays
  • Benefit details for RX, Dental, etc. when applicable
  • Notification of plan and/or PPO network changes
• Large claims history: including total paid claims per individual, diagnosis, prognosis, and expected treatment plan for at least the most recent 36 months
• As stated in the Disclosure Statement, claimants:
  • Currently disabled, confined, have been pre-certified within the last 3 months
  • Have received services that cost 50% of the lowest Specific Deductible amount or $50,000
  • Has been identified as a candidate for case management, having the potential to exceed 50% of the lowest Specific Deductible amount or $50,000
  • Have been diagnosed with a condition represented by the ICD-10 codes