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Single Employer Self-Funded Plan Specifications and request for insurance quote

Are you submitting an amended form?
By indicating that this form is an "amended" form, most of the verification programming will be turned off and you can submit just the changes from the form you originally submitted. First, we must identify the form you want to amend. Please provide the name of the proposed plan sponsor named in the original form.

Plan Information

Employer Information (Proposed Plan Sponsor)
Contact Information
Employer name is required.
Business Type is required.
Please provide further explanation for "other" business type.
Name of CEO is required.
Phone number required in the format (555) 555-5555
Fax number required in the format (555) 555-5555
FID# is required
Address is required
City is required
State is required.
Zip Code is required
Billing Address

Address is required
City is required
State is required
Zip Code is required

General Information

Will any other health plan sponsored by the employer cover any part of employee or dependent health care expenses while this plan is in force?
Please answer yes or no

You must provide a copy of the plan of benefits. You may fax them, or you may upload them in PDF format.

How will you submit your plan of benefits?
Required.
Please upload a PDF file.
Fax your most recent plan of benefits to 913-378-9936 with ATTN: Underwriting
Will any part of the plan be maintained pursuant to a collective bargaining agreement?
Please answer yes or no
Do you wish to provide coverage for on the job injuries to corporate officers, partners, or sole proprietors?
Please answer yes or no
Please specify those you wish to provide on the job injury coverage. Use the (+) button to list all individuals.
Employee Name
Title
Duties
Do you want us to provide you with a sample Section 125 Premium Only Plan document?
Please answer yes or no

The plan number must be a three-digit number between "501" and "599" which must be assigned to this self-funded medical plan by the Employer. It should not be a number you have used before. Any prior self-funded health plans or pension plans may have had a number.

Please refer to your most recent Employee Benefits Plan to determine the next sequential number.

Plan number must be between 501 and 599. Read the directions above for how to determine the appropriate number.
Trustee

Being named a trustee can be a source of liability for the named trustee. For this reason, we recommend that you name the employer as the trustee. Please provide the following information about the plan's trustee.

Please name the Trustee by name or title.
Please provide an address.
Please provide a city.
Please provide a state.
Please provide a valid zip code.
Please provide a contact person for the Trustee
Phone number required in the format (555) 555-5555
Please enter a valid email address.
Contact Person

The Contact Person at the employer will be named in the Summary Plan Description as Correspondent to answer Employee questions and receive Plan correspondence.


Please name the contact person
Phone number required in the format (555) 555-5555
Please provide a street address.
Please provide a city.
Please provide a state.
Please provide a valid zip code.
Current Health Plan Insurance Carrier or TPA

This section asks for information about your current health plan and carrier

Current Methodology of Health Rates
Select the methodology by which your current health rates vary (or select no current coverage).
Please select the methodology of your current health rates.
This field is required
This field is required
Is your current plan self-funded?
Please answer.
Effective Date
Current Employee Only Rate
$
Current Employee & Spouse Rate
$
Current Employee & Child (Children) Rate
$
Current Family Rate
$
Renewal Health Rates
Renewal's Effective Date
Renewal Employee Only Rate
$
Renewal Employee & Spouse Rate
$
Renewal Employee & Child (Children) Rate
$
Renewal Family Rate
$
Eligibility, Participation, and Contribution
Eligible employees are only those employees listed on the Employer’s Quarterly Wage Report and include only full-time employees working for a salary or wage at least 30 hours per week or 120 hours per month. Persons on COBRA and persons in their COBRA election period are also eligible. Retirees are not eligible. Eligible dependents are the employee’s legally married spouse and the employee’s natural children, stepchildren and legally adopted children. Eligible Employees and their Dependents must be resident citizens of the USA or Legal Aliens with legal permission to reside and work in the USA.
Please list below any employees that the Employer considers full-time employees that are not shown on the Employer’s most recent Quarterly Wage Report (for example: owners, new hires, approved leave of absence, temporary layoff, indefinite layoff, part-time, or seasonal).
Are all of your full-time employees shown on the employer's most recent quaterly wage report?
Please answer this question
If the employer pays 100% of the cost of any coverage for the employee and/or dependents, then all eligible employees and dependents must enroll in that coverage even if they have similar coverage elsewhere. If the Employer requires employees to pay any part of the cost of any coverage, then 75% of total eligible employees and dependents must enroll in that coverage. For this calculation, total eligible employees and dependents exclude those with any similar coverage elsewhere, exclude employees in their waiting period and exclude persons on COBRA and persons in their COBRA election period. However, the total number of covered medical employees cannot be less than 50% of the total number of eligible employees including those with similar coverage elsewhere. A waiting period is the time that an eligible employee and their dependents must wait before coverage begins. The waiting period must be in days and cannot exceed 90 days (60 days if first of month following effective date is elected). Coverage may begin the first of the month coinciding with or following the waiting period or the first day following the waiting period.

Please indicate below the waiting period length:
days*
Invalid.
days*
Invalid.

*late applicants must wait until the next available open enrollment period to request coverage

Please indicate when coverage will begin after the waiting period:
This is a required field
Excess Loss
The Excess Loss Policy covers the Employer and not the Employees and Dependents. Therefore, payment of the excess loss premium must be made solely from the Employer’s general account and should not be made from any account containing Plan Assets or employee contributions. The Employer must contribute 100% of the Employee and Dependent Health Plan Excess Loss Premium.
Indicate below the percentage of the cost the EMPLOYER will contribute for each expense:
%
Employee Excess Loss Premium
%
Dependent Excess Loss Premium
%
This field is required
Employee Self-Funded Claim & Administration Costs
%
This field is required
Dependent Self-Funded Claim & Administration Costs

NOTE: If you select 100% of your self-funded claim & administration costs to be paid by the employer, then all full time employees must be covered.

RISK APPRAISAL
Please answer the following questions to the best of your knowledge. For questions answered "yes," provide information on any individual currently covered with your present plan, including any individual covered under COBRA or any other continuation provision. Provide information regarding dependents only if dependent coverage is requested. Additional information may be required by the Service Organization.
To the best of your knowledge, does any individual to be covered have a chronic or ongoing condition, or do any of them have treatment, tests, hospitalization, or surgery pending or have any of them been advised that treatment, tests, hospitalization or surgery is needed (include existing pregnancies and due dates)?
Please answer yes or no
To the best of your knowledge, within the last year has any individual to be covered consulted a doctor or had any medical treatment, tests, hospitalization, surgery, emergency care or outpatient care for cancer, tumor, diabetes, stroke, seizure, mental or nervous condition or any condition for which they received counseling for drug or alcohol abuse or habit, or any disorder of the brain, heart, circulatory system, back, intestines, liver, lung, kidney, immune system, nervous system or muscular system?
Please answer yes or no
To the best of your knowledge, has any individual to be covered been treated for or been diagnosed as having AIDS or ARC (AIDS Related Complex)?
Please answer yes or no
To the best of your knowledge, has any individual to be covered had total claims that exceeded $7,500 in the last 12 months? If you are currently self-funded you must inquire of your current TPA before answering this question. Please provide amount paid and the medical condition and prognosis.
Please answer yes or no
To the best of your knowledge, are any persons on COBRA or any persons in their COBRA election period at this time?
Please answer yes or no
To the best of your knowledge, are any employees not at work due to Total & Permanent or Temporary disability at this time?
Please answer yes or no
To the best of your knowledge, has any individual that is to be covered been absent from work for 10 or more days in the past 12 months due to a medical condition?
Please answer yes or no
OTHER INFORMATION
Other Companies

Provide the following information for Subsidiary/Affiliate companies whose employees are to be covered under the Plan. Provide information on all branch locations.

Does the company contain subsidiary/affiliate companies to be covered under the Plan?
Please answer yes or no
Financial Information
Has your firm ever been denied credit?
Please answer yes or no
Has your firm ever filed bankruptcy or is your firm now in the process of, or considering, filing for bankruptcy?
Please answer yes or no
Funding (Level Funding)
Please select the funding method.
Maximum funding is highly recommended for the first year. Minimum funding can result in claim payment delay.
Please make a selection.
COBRA
Is your group health benefit plan subject to COBRA?
If my group health benefit plan is subject to COBRA, I understand that the COBRA law applies to Employers and that it is my responsibility to comply with the COBRA law. I also understand that the insurance company will only provide excess loss coverage for claims related to “COBRA Employees” if I comply with the applicable COBRA statutes and regulations. I understand COBRA continuation will not be provided if notices and elections are not provided in the required time periods.
If my plan becomes subject to COBRA in the future, I will notify American Trust Administrators, Inc. within 30 days of the date my plan becomes subject to COBRA. I understand COBRA continuation coverage will NOT be provided under my group health benefit plan unless American Trust Administrators, Inc. is properly notified that my plan is subject to COBRA.

Access to Protected Health Information of Employees and Their Covered Dependents

If you do not currently self fund your medical benefits, the Health Insurance Portability and Accountability Act (HIPAA) requires you to appoint individuals to perform plan administrative functions for your Health Plan. These will be the only individuals at your company who may view protected health information on your employees. The Privacy Official will be the person at your company who is in charge of protecting and administering matters dealing with the protected health information of your employees. Other employees disclosed below are the only other employees at your group who will be allowed to view your employees’ protected health information.
If you are currently self-funded you should have already appointed the necessary individuals to receive the minimum necessary Protected Health Information (PHI) to carry out the administration of your group health benefit plan. Please disclose those individuals below.
Please list all employees of the plan sponsor who are authorized to use PHI for health plan administrative functions.
Privacy Official
You may designate the privacy official by name and/or title.
Title and/or Name
Other Employees Entitled to Receive Protected Health Information (PHI)
Complete for only as many employees as you want to have access to PHI. You may designate by name or title.
Employee Name and/or Title

Authorized Signature

I certify that the representations and elections made on this Form are true and correct as of the date signed below. I understand that the truth and veracity of my answers will form the basis for issuance of Excess Loss Reimbursement Coverage. I acknowledge that no benefits are in force and I should not cancel my present insurance until I have been notified of acceptance in writing by American Trust Administrators, Inc., and the proposed health benefit plan has been formally adopted by the appropriate party. I hereby certify that the Employer will pay 100% of the premium for the Excess Loss Reimbursement Contract.

I understand that any material misstatement or failure to provide sought for information may be used as a basis for rescission of the Excess Loss Reimbursement Coverage in which event the sole liability of the insurer would be to refund all premiums paid, less any claims paid. I certify that: (i) every individual who is responsible for the management or direction of the Employer has reviewed this Form, and every other response to any underwriting request made by American Trust Administrators, Inc.; (ii) no such individual has knowledge of or reason to know of a misrepresentation made to American Trust Administrators, Inc. on this Form, or any Employee Enrollment/Refusal Form or in response to any underwriting request made by American Trust Administrators, Inc.; and (iii) no such individual has committed a misrepresentation or assisted, encouraged, or directed any other individual to commit a misrepresentation on this Form, or any Employee Enrollment/Refusal Form, or in response to any other underwriting request made by American Trust Administrators, Inc.

By affixing my name below and clicking the submit button, I certify that the information contained in this document is true and correct and that I am authorized to complete this form on behalf of the employer.

This is a required field.
This is a required field.
ES002 Revised 03/10/2019