American Community

Blue Cross Blue Shield

Humana

Assurant Health

Aflac

Cigna

Aetna

Health Net

United Health One

* Company Name:
* Contact Person:
* Address:
* City:
* State:
* Zip Code:
* Phone:
(XXX)XXX-XXXX
Fax:
(XXX)XXX-XXXX
Nature of Business:
(NAICS code)
Current Carrier:
How Long:
Requested Effective Date:
New Hire Waiting Period:
Total Employees:
Eligible Employees:
Participating Employees:
Out of Area Employees:
Location(s):
COBRA Participants:
  Employer Contribution %:
Employee:
Dependents:
  Current Rates:
Employee:
Spouse:
Child(ren):
Family:
  Renewal Rates:
Employee:
Spouse:
Child(ren):
Family:
To the best of your knowledge, are/have any of your employees:
currently disabled? No
Yes
incurred expenses of $5,000 or more in the last 18 months? No
Yes
been advised that necessary surgery or hospitalization is required (including pregnancy)? No
Yes
had an organ transplant such as kidney, liver, heart, or lung? No
Yes
currently being treated or diagnosed as having cancer, heart/lung disease, high blood pressure, diabetes, muscular skeleton condition? No
Yes
currently taking medication? No
Yes
been diagnosed or is being treated for any other known medical condition? No
Yes
If yes to any of the questions above, please explain:

 

   

 

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