The following is a list of items we need to generate a self-funded proposal and quote. Download the Request in PDF format and Fax to 479-381-7955.
If you need any assistance please don't hesitate to contact us at your convenience.
ITEMS NEEDED FOR A SELF-FUNDED PROPOSAL
1) Census Information – For each plan participant (sex, date of birth, marital status, type of
coverage, home zip code. Total number of employees for Plan Sponsor – to determine participation
2) Summary Plan Description – Most recent Plan booklet or schedule of benefits and limitations.
Also please note any benefit changes considered for the current Plan year.
3) Claims History - Paid claims for at least the last two completed plan years (three years if available) and year-to-date experience for current plan year. By month, if possible, and with RX separated if benefit is through a PBM.
4) Specific or Large Claims - Listing of large claims from Claims History that reached at least 50% of Stop-Loss Contract Specific Deductible in a plan year or may in the current year. Please specify employee or dependent, the total dollar amount of the claim, diagnosis/ prognosis.
5) Specific Deductible – Level(s) of per claim retention ($15,000, $25,000, etc.) that Plan sponsor will consider.
6) Stop Loss Policy Information – Current Specific Deductible, Current Aggregate attachment point/aggregate factors. Current Stop Loss Insurance specific and aggregate rates. Current Stop Loss Policy contract basis (12/12, 12/15, 15/12), type of contract desired.
7) Plan Sponsor Information - Nature of business (SIC Code), Zip codes of various locations. Amount (%) employer (plan sponsor) contributes toward employee only monthly premiums, employee and dependent monthly premiums.
8) Name of Current PPO Network
9) Name of Current PBM for RX card if applicable
10) Life Insurance - Is life insurance quote requested? If so, what life amount should be quoted?
Optional items: List of Provider ID numbers and zip codes for PPO review
Proposed Plan Changes – either to benefits or deductibles / co-pay
Excel Format is preferable f-or items 1 & 3
You may submit by mail to:
S B Howard & Company
P. O. Box 1627
Rogers, AR 72757-1627
Or by e-mail to:
leesad@sbhoward.com
