Document 283221
1. Employee Census Information All eligible employees must be listed on the census. Please refer to the detailed census information on the example below. (Note: The employee census spreadsheet must be submitted electronically. Please e-mail census information to CoventryMDLGQuotes@cvty.com or CoventryDELGQuotes@cvty.com. Submit below-formatted Excel spreadsheet to avoid processing delays. Sample of Census Information (please submit census in formatted Excel spreadsheet as shown.) Last Name First Name Rubble Barney Plan Type POS TIER DOB GENDER ZIP Family 11/11/1970 F 20859 2. Current Carrier Information Provide copies of the following: Current Health Insurance Carrier(s) Current and Renewal Plan Design(s) and Benefits on carrier letterhead Current Rates and Renewal Rates (up to 2 years) on carrier letterhead If available, but required for 100+: Claims and Enrollment experience and high claimant info, to include amount, status, and diagnosis (Note: If any of the above is missing, this will delay the processing of your quote. Please include any additional documentation available to assist underwriting.) 3. Large Group Employer Risk Appraisal Questionnaire (RAQ) Complete and sign the attached three (3)-page questionnaire. 4. Submit a Quote Request The above documents must be submitted by email: CoventryMDLGQuotes@cvty.com for Maryland OR CoventryDELGQuotes@cvty.com for Delaware 5. Broker name _________________ and commission percentage ___ %. Provide Broker name and commission percentage (%) above. (Maximum percentage allowed is 5.00%) Large Group Quote Checklist rev. 08.11 Page 1 of 1 © 2011 Coventry Health Care of Delaware, Inc. Employer Risk Appraisal Questionnaire CHCDE/CHL – 1001.2 – RAQ 4/10 Employer Risk Appraisal Questionnaire 51 + Eligible Employees This questionnaire is designed to provide information specific to your group and will be used by Coventry Health Care of Delaware, Inc./Coventry Health and Life Insurance Company (CHCDE/CHL) in evaluating the risk characteristics to more accurately establish rates, benefits, and eligibility rules as part of your application for coverage. Please choose one company: Coventry Health Care of Delaware Coventry Health and Life Insurance Company I. GENERAL INFORMATION Company Name Company Address City/State/Zip Phone Number Requested Effective Date Nature of Business & SIC Years in Operation Reason Out to Bid Please list any employer locations other than noted above. II. GROUP ELIGIBILITY Total Employees Full-time Part Time Total Eligible for Coverage Total Waivers Retiree COBRA Please see your CHCDE/CHL rate proposal for complete eligibility and quoting policies. Please identify on census or attach a list of all: COBRA: former employees and/or dependents covered or eligible to receive coverage under state or COBRA continuation. Please list employees’ termination date. Retirees: if eligible for coverage with CHCDE/CHL Out of Area employees/members applying for coverage with CHCDE/CHL. Employer Contribution: Employee Dependent Waiting Period Are all eligible employees covered by Workers’ Compensation? Yes No If no, please explain: III. COVERAGE INFORMATION (List all health carriers in the last three years) Carrier RATES Effective Date Employee Reason for Change EE/Spouse EE/Child(ren) Family Current $ $ $ $ Renewal $ $ $ $ Plan Description* *Please attach a current benefit summary(s) for the most recent 2-year period. Previously covered by CHCDE/CHL? Yes No CHCDE/CHL – 1001.2 – RAQ If Yes, date covered: ____________________ 4/10 IV. HEALTH INFORMATION Provide the answers to the following questions as they pertain to all eligible employees and/or covered dependents (including COBRA, any state continuation programs, and eligible retirees). A. To your knowledge has any person (employee and/or employee’s dependents, or COBRA individuals) to be covered been diagnosed or treated by a provider for any of the following conditions within the last 5 years? (Please check Yes or No. If yes, please circle all conditions that apply.) 1. Alcohol or substance abuse Yes No No # of people: ______ 2. Arthritis Yes No No # of people: ______ 3. Asthma, emphysema, cystic fibrosis, or other lung disease Yes No No # of people: ______ 4. Diabetes: Type (if known)______________ Yes No No # of people: ______ 5. Cancer Yes No No # of people: ______ 6. Epilepsy/seizure disorder Yes No No # of people: ______ 7. Disorder of the spine, back, joints, bones Yes No No # of people: ______ 8. High blood pressure Yes No No # of people: ______ 9. Heart disease Yes No No # of people: ______ 10. Stroke, paralysis Yes No No # of people: ______ 11. Kidney or bladder disease, kidney dialysis Yes No No # of people: ______ 12. Liver disease or hepatitis: Type (if known)______________ Yes No No # of people: ______ 13. Multiple sclerosis, muscular dystrophy, or cerebral palsy Yes No No # of people: ______ 14. Psychological or other mental disorder Yes No No # of people: ______ 15. Organ transplant (planned or past) Yes No No # of people: ______ 16. HIV/AIDS Yes No No # of people: ______ 17. Tuberculosis Yes No No # of people: ______ 18. Colitis or Crohn’s disease Yes No No # of people: ______ 19. Any condition or disease not mentioned above, or anticipated surgery Yes No No # of people: ______ For each item checked “YES,” please explain in section D on the back of this page. B. Have any employees, dependents, or COBRA individuals who are eligible for coverage incurred claims that have exceeded $10,000 (medical and/or pharmacy) during the last 12 months? Yes No Please explain in section D. Are any employees currently disabled or otherwise not actively-at-work? (Give medical details and date disability started.) Yes___________________________________________________________ No C. Are any eligible employees or dependents currently pregnant? Yes How many? ____ Ages _________ Due Dates ___________________ CHCDE/CHL – 1001.2 – RAQ No 4/10 D. Please explain any “YES” answers in this space. Please indicate what question you are answering. If more space is needed, attach a separate sheet. Please sign and date all attachments. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ V. STATEMENT OF UNDERSTANDING I understand and do hereby certify that the information contained in this Employer Risk Appraisal Questionnaire is complete and accurate to the best of my knowledge. I further certify that I hold a position with the company that permits me to have the information necessary to complete this Employer Risk Appraisal Questionnaire on behalf of the company or I have conferred with and confirmed my answers with person(s) that hold such position(s) with the company. It is further understood that CHCDE/CHL reserves the right to re-rate or rescind coverage if any supplied information is an intentional misrepresentation of a material fact. I understand that CHCDE/CHL may contact employees and dependents to obtain additional follow-up information. I agree to inform employees that CHCDE/CHL may contact them in order to obtain additional information or to discuss information provided on this form. Employer agrees to indemnify CHCDE/CHL for any liability or damages resulting from any breach of representation made in this form and for claims brought by employees and their dependents regarding the use of the information disclosed by employer. Signature: _________________________________ Print Name: ___________________________ (Company Executive or Senior Human Resources employee) Title: Phone Number: _______________________________ ____________________________________ Date Signed: ______________________________ Broker Name (Print): ____________________________ Broker Signature: _______________________________ CHCDE/CHL – 1001.2 – RAQ Date of Broker Signature: ____________________ 4/10
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