| General Information |
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*Company Name:
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*Address of Principal Location:
Line 1
Line 2
City, St. Zip ,
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*Requested Effective Date:
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*Current Contract-Type:
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*Current Administrator:
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*Current Re-Insurance Company or Fully-Insured Carrier:
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*Specific Attachment Point:
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*Specific Current Contract:
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*Requested Specific Contract:
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*Current Aggregate Contract:
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*Requested Aggregate Contract:
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*Current Deductible:
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*Current Stop-Loss:
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*Current In-Network Coinsurance:
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*Current Out-of-Network Coinsurance:
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*Current Office Visit Copay:
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*Current Rx:
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*Requested Plan Design:
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* These items will need to be
remitted to NovaSys Health in order to process your
request for quote. The more information you send,
the more competitive your quote. Transmission of PHI requires
a login. Upon receipt of your request for quote, NovaSys
will provide you with a password, login, and upload
directions.
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| Additional Information |
Paid claims, by month if possible, for the current claim experience period and for as much prior period as possible with a minimum of twelve (12) months of concurrent claims information.
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Numbers of employees, by month if possible, for the current claim experience period and for any prior claims periods being reported. If monthly census is not available for prior periods, an estimated annual average enrollment is very helpful.
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Current employee census, including gender, date of birth or age, single or family status. Identify individuals who are COBRA participants, retirees, ineligible, or not covered. If not covered, identify those with coverage elsewhere.
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A copy of the group's current benefit plan design indicating any plan design changes desired for the coming year.
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Details of any individual claims that exceeded 50% of the specific deductible applicable to the current claim experience period including claim amount, incurred and paid dates, diagnosis, prognosis, and current status.
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Details of any known current disabilities or ongoing claims that may reasonably be expected to exceed 50% of the specific deductible requested in the upcoming year.
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Current and renewal rates (if available).
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Copy of current Plan Document, Summary Plan Description (SPD), or summary description of plan benefits.
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Are expenses incurred at your own hospital currently reimbursed by the carrier at a level other than 100% (for use when writing Hospital or physician practice risks)?
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