Proposal Request Form

Data Request

For all reports and data outlined below, include at least 24 months of claims experience, providing the most current data. This can be done in one of two ways:

1. 24 months of data in two 12-month periods, including the most recent months (preferred).
2. Plan year data, with at least 24 months data, including the most current months data. 

In either case, the end date of the experience period must be within 3 months of the requested effective date to be considered credible.

Please note the data requested is REQUIRED for a proposal to be issued. If the appropriate data is not provided, RFPs will be pended until all files are received.

High cost claimant report (HCC)

Fully-funded: Any members over $25K in claims (ideal) or 50% of pooling
Self-funded: Any members over 50% of the specific deductible

• Must be received in the same period in which monthly claims experience is sent
• Diagnosis and prognosis information
• Note whether the large claimants are still eligible for the plan and if still enrolled
• For plans with an HRA, provide balance report with employer funding amounts
  
  

Census Information

Please upload a census that contains all information required to quote all lines of coverage selected.  Please download one of the following templates if needed.  Once opened in your browser, click file>download to manipulate a copy.

• 2-50 census template
• 51+ census template

For small group medical only coverage, the following infromation is REQUIRED for each enrolling member:

1. First Name
2. Last Name 
3. Relationship (EE, SP, CH)
4. Date of Birth
5. Enrollment Status

For ancillary only coverage and large group medical, the following information is REQUIRED for each eligible employee:

1. First Name
2. Last Name
3. Home Zip
4. Date of Birth
5. Gender
6. Medical Enrollment Tier
7. Medical Plan
8. Dental Enrollment Tier
9. Dental Plan
10. Vision Enrollment Tier
11. Vision Plan
12. Enrollment amounts for vol. life/vol. disability options
13. Zip Code
14. Hire Date
15. Job Title
16. Job Class
17. Compensation