Fillable MASTER APPLICATION FOR SMALL GROUP EMPLOYERS (Dickerson Insurance Services)

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MASTER APPLICATION FOR SMALL GROUP EMPLOYERS (Dickerson Insurance Services)

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B850 (Rev 11/10/20 NRM) 1 Effective 01/01/21
MASTER APPLICATION FOR SMALL GROUP EMPLOYERS
COMPANY INFORMATION
Exact Legal Name of Company:
“Doing Business As” (DBA):
Street Address
City
State
Zip Code
Billing Address (if different from above):
City
State
Zip Code
Tax ID:
Type of Business:
Years in Business:
Key Contacts (please complete):
HR Manager is also Billing Contact
HR Manager: Phone: ( ) E-mail:
Billing: Phone: ( ) E-mail:
Company Officer/Owner: Phone: ( ) E-mail:
MediExcel Health Plan is an environmentally conscious organization that takes great pride in reducing paper waste. By signing our Master Application,
you acknowledge that all Plan documents, including invoices will be sent to you via e-mail.
CA Coverage Health Insurance Carrier(s):
Name of Current Workers’ Comp Carrier:
Other Health Insurance Plans Offered:
Premium Billing Reference:
Bill one locations Bill Multiple Locations
Requested Effective Date:
Yes No
Are you changing cross-border providers? Yes No
Yes No
PLAN SELECTION
MediExcel Health Plan Offering:
P5 Platinum HMO Plan
P10 Platinum HMO Plan
Platinum 90 HMO 0/20 INF Plan
Gold 80 HMO 250/35 INF Plan
*Min. 3 EEs required for P5, P10, Platinum 90 Plans
Choose Dental Plan option:
D100 D200
Choose tier level:
3-Tier 4-Tier
*CAN BE OFFERED AS VOLUNTARY
No Dental Plan option
Confirm Vision Plan option:
V100
Choose tier level:
3-Tier 4-Tier
*CAN BE OFFERED AS VOLUNTARY
* ACTIVE MEDIEXCEL MEDICAL COVERAGE REQUIRED
No Vision Plan option
OWNER/CORPORATE INFORMATION
Company is a: Sole Proprietor Partnership or LLC Corporation Non-Profit
REQUIRED ENROLLMENT INFORMATION
Total # of
Employees: ____
Total # of Benefit
Eligible Employees:____
Total # Enrolling in
MediExcel Health Plan: ____
Total # Enrolling in other
Employer Sponsored Plans:___
Total # Declining
Coverage: ______
REQUIRED COBRA INFORMATION
Is your group currently subject to Cal-COBRA? Yes No
(Employed 2-19 employees during at least 50% of the working days in the previous calendar year or previous quarter if not in business in the previous
calendar year, and are not subject to Federal COBRA)
Is your group currently subject to Federal COBRA? Yes No
(Employed 20 or more total employees during at least 50% of the working days in the previous calendar year)
Number of existing COBRA or Cal-COBRA participants: _________
Name of your COBRA or Cal-COBRA Administrator: _____________________________________________________
B850 (Rev 11/10/20 NRM) 2 Effective 01/01/21
Number of hours required per week to be eligible for benefits:
Full-time EE’s: 30 hours 40 hours
Other _________________
Do you want to cover part-time employees that work 20-29 hours?
Yes No Other _____________________
Employer Contribution Levels:
Employee________% or $________
Dependent________% or $________
Waiting Period for New Hires and Rehires
1
st
of the month following _______________ days (for new hires). 1
st
of the month following _______________ days for (rehires).
Application is hereby made for a MediExcel Health Plan Group Subscriber Agreement. This is an application only. Issuance of a Group Subscriber
Agreement is subject to receipt of first month's premium and review and approval by MediExcel Health Plan. All eligible employees and dependents
will be offered this benefit package. If accepted, the employer agrees to make required payroll deductions based upon the contributions established
herein for all employees who enroll in this plan. The applicant also agrees to notify all eligible employees of their ability to enroll in the plan after their
waiting period.
Administrative Fees: (Fees waived for 4 Enrolled Employees or more)
• 3 Enrolled Employees: $10.00 monthly administrative fee.
• 2 Enrolled Employees or less: $15.00 monthly administrative fee.
*Dependents are not included towards count.
_______________________________________ _________________________/__________________________ ____________
X Signature of Company Officer or Owner Print Name and Title Date
MANDATORY BROKER/ GENERAL AGENCYINFORMATION (PLEASE COMPLETE BOTH SECTIONS)
Broker Agency:
Broker Name:
Broker/Agent Signature: ___________________________________
Date: _____________________
Tax ID: _____________________
License #: _____________________
Telephone #: _____________________
General Agency (please check one): Yes No
General Agency Name:
Tax ID: _____________________
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MASTER APPLICATION FOR SMALL GROUP EMPLOYERS (Dickerson Insurance Services)

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Completed 1 June 2021

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