Fillable Affordable Care Supplement (Risk Placement Services, Inc.)

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Affordable Care Supplement (Risk Placement Services, Inc.)

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QBE and the links logo are registered service marks of QBE Insurance Group Limited
QBPC 30 06 09 15 Page 1 of 2
Instructions
To be completed in respect of Health Insurance only.
Information
1. Does your Agency place or intend to place any Health insurance in the next 12 months?
Yes
No
If no, none of the following questions are relevant to your Agency, so just sign and date this supplement after question 12.
If yes, complete questions 2-11.
2. What was your total commission for the last 12 months?
$
3. What was your total premium volume for the last 12 months?
$
4. What was the split over the last 12 months?
Group Health PV
Number of policies written
Individual Policies PV
Number of policies written
5. What percentage of your business for the next 12 months do you anticipate placing with
Federal or State Exchange(s)/Marketplace(s)
%
Open Market Insurers
%
6. Would you allow any member of your staff to act as a navigator?
Yes
No
If yes, provide full details
7. List your open Market Insurers
Insurer
# of plans available
8. Are all staff members who service your clients licensed by the DOI?
Yes
No
If no, provide full details
9. Do you have a specialist(s) in your Agency who only places health insurance?
Yes
No
If yes, provide the following information
Name of individual
Professional Designation
Number of hours education received concerning ACA in the last 12 months
Identity of the professional body providing education
Is this person(s) certified by CMS?
Yes
No
Have they registered as an Agent/Broker with the ACA Health Insurance Marketplaces through
the CMS enterprise portal (CMS.gov)?
Yes
No
Number of years' experience in the field of Health Insurance
(use additional sheets where necessary)
10. Do you accept business from sub-producers
Yes
No
11. When your Insureds receive notice of non-renewal is your procedure for replacement coverage
any different if the non-renewal notice is because of the ACA?
Yes
No
If yes, provide full details
Affordable Care Supplement
QBPC 30 06 09 15 Page 2 of 2
12. Do you provide any financial advice concerning the exchange/marketplace vs the open market?
Yes
No
If yes, provide full details
Signatures
Applicant's name
Title (Owner, partner etc.)
Applicant’s signature
Date
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Affordable Care Supplement (Risk Placement Services, Inc.)

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Completed 23 November 2020

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