MCO Application

Application for Self Funded Stop Loss

 

Name 

Date Needed 

Effective Date 

Address

County

City

State

Nature of Business

SIC CODE

;

Number Loc

;

Number of: EE's.

Number of Single

Number of Family

Total

 

Deductibles:

Specific:

$50,000

;

$75,000

;

Other $

Aggregate:

Standard

;

125%

;

Spec Adv

;

TL

;

AA

 

For Current Plan:

Yes

No

(Revised Plan: Please have subscriber agreement benefits)

Please state plan changes from previous year

 

Lifetime Max Payment

$1,000,000

$Other

 

Aggregate Coverage in addition to Medical Cost Containment?

Steerage/ National/ Local PPO? Yes No

PPO Name

 

Please provide the following coverage proposal for: (Check desired coverages)

   

Life

TPA

AD&D

Legal

Dental

Mental Health

Transplant

Rx

Vision

Rx Risk Program

 

Current Medical Stop Loss Term: (Check one)

Fully Insured;

15/12

12/15

12/12

12/24

Curr Specific Level $

 

Rate History:

Aggregate Factors (If self insured)

 

Current

Renewal

Life/$1000

AD&D

Retention

Employee

Dep

Composite

 

Current

Renewal

Single

Family

Employee

Dependent

Composite

Employer Contributions %; Employee %; Dependents %

 

Large Claim History:

Please Attach the Following Reports:

· Completed Application

· Network Descr.-Transplant, NICU and Burn case rates or per diems

· Census (Age/Sex/Single/Family)

· Past two yrs claims by member months

· Current Plan Benefits

· Paid Claims past two years (Policy years)

· Plan Changes

· Copy of current stop loss policy coverage & rates

 

Please Provide Details of any claims greater than $10,000 Large Claim History (2 yrs):

Include in report:

·

Diagnosis

·

Amount Paid

·

Prognosis

 

Are any Empls or Depnds. disabled or have any major health problems? Yes No

If you answerd yes to the above question please provide additional information in the text box below.

Are any Empls or Deps currently eligible for COBRA? Yes No

If you answerd yes to the above question please provide additional information in the text box below.

Current Carrier

 

Contact Information & Comments

Contact Name 

Title 

Contact Number 

Additional Comments

 

 

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