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GROUP INSURANCE CENSUS FORM – HEALTH, DENTAL, LIFE, VISION & DISABILITY |
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www.RxMom.com
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Company Name:_____________________________________________
Contact: _______________________Type of Business______________
Address:____________________________________________________
City: __________________________ State: _________ Zip:_________
Telephone: ________________________Fax:_____________________ Email:______________________________________________________ |
Return to: Tom Musembi
RxMom.com Insurance Services
Insurance@RxMom.com
Fax: 866-707-9532
Bus: 888-490-8782 |
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EMPLOYEE
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DEPENDENTS |
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Employee Name |
M/F |
Birthdate |
Home Zip Code |
Annual Income
(For Disability & Life) |
Spouse / Partner
(Yes/No) |
Spouse / Partner Gender |
Number of Children |
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1 |
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2 |
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9 |
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10 |
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11 |
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12 |
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13 |
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14 |
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15 |
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Employee Name |
M/F |
Birthdate |
Home Zip Code |
Annual Income
(For Disability & Life) |
Spouse / Partner
(Yes/No) |
Spouse / Partner Gender |
Number of Children |
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16 |
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17 |
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18 |
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25 |
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Quotes Required : [ ] Medical Insurance, [ ] Dental , [ ] Vision, [ ] Short Term Disability, [ ] Long Term Disability |
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Effective Date Sought: |
Carriers Requested: |
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Life Benefit: |
STD Duration: |
STD Benefit: |
LTD Benefit: |
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Additional Requests:
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Please Print Additional Copies of Census Form as Needed
Confidential Group Health Insurance Field Underwriting Questionnaire
Our approach is to become more intimate with your unique Group Health Insurance needs in order to address your concerns and streamline the bidding process. We appreciate your valuable time for answering each of the questions below and sincerely look forward to serving you and building a long-term relationship. Thank you very much.
- Please complete the attached census and provide the following information for your existing plan(s):
2. Briefly explain any concerns or frustrations your group may be experiencing with your current carrier(s), insurance plan(s), brokerage firm or other.
3. Summarize your company's goals, objectives and expectations for this exercise.
4. Provide the following information for your existing plan(s):
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Coverage Type |
Carrier Name 1 |
Plan Name 1 |
Carrier Name 2 |
Plan Name 2 |
Renewal Date 1 |
Renewal Date 2 |
Mo. Prem. Carrier 1 |
Mo. Prem. Carrier 2 |
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Medical |
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Dental |
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Life |
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Vision |
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Short Term Disability |
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Long Term Disability |
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5. In order to manage the cost of your benefits program, would you like to: (Choose Letter(s) _____
- Learn about “Consumer Driven Plans”
i.
Health Savings Accounts
ii.
Health Reimbursement Accounts
- Learn about “Employer Defined Contribution” programs
- Learn about “Minimum Premium Funding” (requires 25+ participants)
6. In designing your medical insurance plan, mark “XXX” your preference from the following options:
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Dr. Co pay |
$10 |
$15 |
$20 |
$25 |
Other |
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Deductible |
$250 |
$500 |
$750 |
$1000 |
Other |
7. In designing your medical insurance program, would you like to: (Choose Letter) _____
a.
Offer PPO only
b.
Offer HMO only
c.
Offer a combination of HMO and PPO plan options
8. If employees contribute to their premiums or they pay for their dependent costs, are these premiums paid on a:
(a) Pre-tax or (b) Post-tax basis? (Choose Letter) _____
9. How important is it to offer Kaiser? (Choose Letter) _______
a. Not important b. Somewhat important c. Very important