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

;

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