Fillable Health Insurance Carrier Survey (Department of Technology and Information)

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Health Insurance Carrier Survey (Department of Technology and Information)

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U.S.A. forms for Department of Technology and Information

BROWSE DEPARTMENT OF TECHNOLOGY AND INFORMATION (DE) FORMS

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Health Insurance Carrier Survey
Date Completed __________________
Insurance Company ______________________________
NAIC# __________________________
Toll Free Consumer Contact Telephone Number ______________________
Please check all Line of Authority that your company markets in Delaware.
_____Group
_____ Large Employer (50+ Employees) _____Small Employer _____AHP/MEWA Plans
_____ Blanket Insurance _____ Fixed Indemnity Insurance _____ HRA/HSA High Deductible
_____Disability Income Plans _____Short Term Disability _____ Long Term Disability
_____Dental _____Vision _____ Miscellaneous (List plan types below)
_____Individual
_____Comprehensive Major Medical _____PPO _____POS _____HMO _____MCO
_____AHP/MEWA Plans _____HRA/HSA High Deductible _____Fixed Indemnity Plans
_____Disability Income Plans _____Short Term Disability _____Long Term Disability
_____Dental _____Vision _____Miscellaneous (List plan types below)
_____Long Term Care Insurance
_____Federally Qualified Plans _____Group ____Individual ____LTC Partnership Plans
_____Medicare Supplement Plans: Please indicate which plans the company markets.
Comments and Notes:____________________________________________________________
______________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________________________________________
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Health Insurance Carrier Survey (Department of Technology and Information)

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Completed 13 August 2020

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