Fillable Form 101: CENSUS & REQUEST FOR QUOTE (Dickerson Insurance Services)

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Form 101: CENSUS & REQUEST FOR QUOTE (Dickerson Insurance Services)

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The Form 101: CENSUS & REQUEST FOR QUOTE (Dickerson Insurance Services) form is 2 pages long and contains:

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File type: PDF

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HMO PPO Kaiser
EE
EE/SP
EE/CH
FAM
Carrier Name Type of Coverage Period Insured or # of Years
1
2
3
4
5
Broker Information Group Information
4
Company/Group Name: _____________________________________
Address: _________________________________________________
City: _____________________________________________________
State: ____________________ ZIP Code: _______________________
DBA: ______________________ Phone: _______________________
Nature of Business:
________________________________________
SIC Code: ________________Years in Business: __________________
Eective Date: _____________ Waiting Period: __________________
# (non-COBRA) Eligible Employees: _________________
# COBRA Employees: ____________________________
Date: ____________________________________________________
Broker Firm Name: _________________________________________
Producer Name: ___________________________________________
Broker Address: ____________________________________________
City: _____________________________________________________
State: ____________________ ZIP Code: _______________________
Phone: ________________________ Fax: _______________________
Email: ____________________________________________________
Broker of Record? Yes No
Common ownership with other companies? Yes No
4
Medical Information 5-Year Carrier History
4
If Kaiser is Present: Kaiser Will Remain Total Replacement
Employer Contribution Amount: HMO
per Employee: __________________
per Dependent: _________________
Employer Contribution Amount: PPO
per Employee: __________________
per Dependent: _________________
Current Rates Renewal Rates
4 4
HMO PPO Kaiser
EE
EE/SP
EE/CH
FAM
If age banded, please attach billing statement Please attach complete renewal, including large claims report
Please attach benet summary(ies)
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Current Benets Description
4
101
+
CENSUS & REQUEST FOR QUOTE
Submit Completed Census to your dedicated Account Executive or submit by email to sales@dickerson-group.com
1918 Riverside Dr. • Los Angeles, CA, 90039
800-457-6116 • 323-662-7200 • License #0M29112
Carriers to be Quoted
4
Kaiser Anthem Blue Cross Cigna Health Net Aetna Blue Shield
101-300 Call for details 25-250 101-500 Call for details Call for details
Medical:
HMO PPO HSA POS
Plans to be Quoted
4
Current Carrier: ___________________________________________________________________________________________________
Current Benets __________________________________________________________________________________________________
Current Rates: ___________________________________________________________________________________________________
Requested Benets: _______________________________________________________________________________________________
Life:
Dental:
Current Carrier: ___________________________________________________________________________________________________
Current Benets: Please attach benet summary(ies)
Current Rates: ___________________________________________________________________________________________________
Requested Benets: _______________________________________________________________________________________________
Vision:
Current Carrier: ___________________________________________________________________________________________________
Current Benets: Please attach benet summary(ies)
Current Rates: ___________________________________________________________________________________________________
STD/LTD:
Health Questions
4
Amount: ___________________________________________ Basis: _______________________________________________________
1. Has any insured received medical benets in excess of $15,000 in the last 12 months?
If YES, please provide details: ___________________________________________________________________ ____________
2. Are there any disabled participants?
If YES, please provide #: _______________________________________________________________________ ____________
3. Are ther any catastrophic or other serious medical condiditions, pregnancies, or coverage of members
not actively at work, or currently hospital-conned?
If YES, please provided details: __________________________________________________________________ ____________
For pregnancies, please provide #: _________________________
4. Are all employees covered by workers’ compensation insurance?
if NO, please provide # not covered: ________________________ ____________
5. Has any owner or principal led bankruptcy within the past seven years,
or known to be planning to le bankruptcy? ____________
6. Does the employer reimburse employees for any part of their normal out-of-pocket costs? ____________
(copays, deductibles, coinsurance, etc.)
Note: The group may not self-insure any part of the employees’ normal out-of-pocket costs or provide any type of “GAP Insurance.”
7. Reason for shopping: (mark all that apply) Market Check Unhappy with Rates Unhappy with Benets
Other: _____________________________________________________________________________________________________
___________________________________________________________________________________________________________
Yes/No
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Form 101: CENSUS & REQUEST FOR QUOTE (Dickerson Insurance Services)

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Completed 1 June 2021

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