CONFIDENTIAL GROUP INSURANCE ANALYSIS
 
Company Name:
Address:
Telephone Number:
Contact:
Clarity Life Ins Insurance Approval/Date:  (mm/dd/yyyy)
 
GENERAL BUSINESS QUESTIONS
 
1.Describe the scope of your business.
2.How long have you been in business?
3.How many employees do you have?  (M)  (F)
4.How many locations do you have? (Describe)
5.How many employees at each location? (if more than one)
6.Do you have a union? (if yes) what is the contract renewal date?
7.Do you belong to any trade associations?
8.Who is/are your current benefits carrier(s)?
 
ADEQUACY COVERAGE QUESTIONS
 
1.What benefit plans do you offer your employees? (e.g. medical, dental, retirement, life, disability, etc. – current benefits summary/ies must be provided.)
2.Does the employer pay full cost? (current bill must be provided)   ( if not) What percentage does the employee pay?
3.How often are claims submitted and not fully paid? (E.G. Hospital room and board, surgery, la service, dental, vision care, disability, life, etc.)
4.(if you have a pension plan) Is your plan a defined contribution or defined benefit plan?
5.(If you have a profit sharing plan or 401k) Are any employee contributions required?
6.What benefits (if any) have employees requested which you do not currently provide?
7.Why have you not provided them? (e.g. cost, availability, etc.)
8.What do you like most about the coverage you have? (i.e. level of benefits) Why?
9.How long have you been insured with them? % annual turnover?
 
SERVICE FROM CURRENT BROKER
 
1.How are your benefit coverages funded? (e.g. traditional, MPP, ASO, self-funded, etc.)
2.How were benefit plans determined?
3.How is your current broker helping you reduce costs and losses? (e.g. Section 125, claims analysis, verifying applicable rate applications, modifying waiting periods, verifying trend, actuarial services, consumer driven health plans, HSAs, HRAs, etc.)
4.How often does your broker contact you to discuss changes in coverages and innovations? (e.g. HMO, PPO, PEO, COBRA, TEFRA, etc.)
5.Do you receive necessary paperwork on a timely basis? (e.g. Enrollment forms, benefit booklets, ;plan summaries, etc.)
6.Does your broker or benefits provider periodically explain the provisions of your plans to your employees?
7.Do you have more than one source for your various coverages?
8.Does your present broker advise you of alternate methods to fund your employee plans?
9.Are you aware of the financial ratings of your carrier(s)?
10.What do you like most about the current borker’s service?
11.What do you like least about the current broker’s service?
12.Is there anything more that you feel we should discuss regarding your current broker’s service?
 
SERVICE FROM CURRENT CARRIER QUESTIONS
 
1.How often do you meet with insurance carrier personnel to discuss your account? (e.g. underwriting, claims, premium audits, etc.)
2.How often do you receive insurance carrier generated information? (e.g. loss runs, premium recap, new benefit information, etc.)
3.Does your broker receive on a timely basis, necessary paperwork from insurance carriers? (e.g. enrollment cards, claim checks, benefit booklets, etc.)
4.What do you like most about the service from your current carrier?
5.Is there anything more you feel we should discuss regarding the current carrier’s service?
 
ACCESS TO INSURANCE MARKETPLACE
 
1.Does your present broker show you competitive quotations?
2.What coverages or limits have you requested but not been able to obtain? (why not)
3.Does your current group medical plan contain provisions for dividends or return premiums?
4.Is there anything more that you feel we should discuss regarding your access to the insurance marketplace?
REQUEST FOR PROPOSAL
Date: (mm/dd/yyyy) Requested Effective Date (mm/dd/yyyy)
Bids Due: (mm/dd/yyyy)
ATTACHMENTS (Check all that apply) GROUP INFORMATION
Claims Experience: Name of Group:
Current Benefits: County or Zip Where Billed:
Recent Billing : Type of Business:
Health Statements: # of Years in Business:
Select risk Question: Anniversary Date: (mm/dd/yyyy)
Census Sheets: # of Carriers in Last 5 Years :
Are more than 25% of employees related?
# of Full-time Employees in Firm?
Does Group need a Pre-existing condition take-over?
Present Carrier: Present Rates: Single
Familiy
Renewal Rates: Single
Family
Employer Contribution: Single Dependents
OPTIONS REQUESTED: Deductible:
 Coinsurance
 Maximum out of pocket
Maternity: 
   
Life: Minimum
Other

(list on census)
STD:
Specifications
Ltd:
Specifications
OTHER OPTIONS Dental
Vision
Drug Card
NOTES:
GROUP CENSUS
 
S.No.NAMEAGE/DOBSEXMEDICALDENTALVISIONLIFE
1        
       
Legend: E = Employee, S= Employee and Spouse, C=Employee and Child,F=Family
SELECT RISK QUESTIONNAIRE
Group Name:
Contact:
Phone:
Case Manager:
Date (mm/DD/YYYY)
Eligibility/Participation
Total number of *eligible employees
Total number of employees enrolling
Total number of retirees participating
Total number of COBRAs
TO THE BEST OF THE EMPLOYER'S KNOWLEDGE:
Are there employees who are not actively at work performing
his or her duties full time due to illness or injury?
If yes, how many?
Details:
Are there employees or dependents
who are expected to be hospitalized for
a serious medical condition in the next 12 months?
If yes, how many?
Details:
Are there employees or dependents with an
existing pregnancy (answer for groups under 50)?
If yes, how many?
Are there employees or dependents
who are currently hospitalized or treatment facility?
If yes, how many?
Details:
Are there handicapped children over the age of 19,
who are covered under the prior insurance
plan to be insured under this plan?
If yes , how many?
Details:

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