LISH Hawaii Limited Benefit Medical Plan Employer Checklist

Transcription

1 LISH Hawaii Limited Benefit Medical Plan Employer Checklist Thank you for your interest in the Limited Benefit Medical Plan offered to you by LISH Hawaii. In order to enroll in this plan, you will need to submit the following documents to Imperia TPA: Transamerica Life and Health Group Application and Agreement (Completed by Employer) Premium Collection Agreement TransChoice Plus Employee Enrollment Form (Completed by each employee that is enrolling in coverage) Payment Selection Option 1: Payroll Deduction Deduct the monthly premiums from each employee s paycheck and submit one check for the total amount to Imperia TPA. Option 2: Employee Direct Pay For the initial payment, you (employer) will need to collect the first month s premium from each employee. Please make checks payable to Imperia TPA. Monthly Premium Agreement (Completed by each employee) First Month s Premium (either one check from employer or collected checks from employees) Please return entire packet, all forms, and checks to the address below. For expedited service, you can also fax the forms to E. Camelback Road, Suite B-240 Phoenix, Arizona p f

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4 Premium Collection Agreement ("Employer") wishes to serve as its Premium Collection Administrator ("Administrator"). The Administrator's duties under this agreement include handling of all premium billing matters and collection matters on the behalf of the Employer in connection with certain insurance policies/certificates issued to the employees of the Employer. Transamerica Financial Life Insurance Company, Transamerica Life Insurance Company, Transamerica Occidental Life Insurance Company, Life Investors Insurance Company of America, and Monumental Life Insurance Company are herein after referred to, collectively, as "the Company". Employer wishes to have the Administrator handle the premium billings received and the premiums collected in connection with the policies/certificates issued by the Company to Employer's employees under the Company's group billing c o n t r o l n u m b e r ( s ) T h e E m p l o y e r a n d A d m i n i s t r a t o r ( " p a r t i e s " ), therefore, agree as follows: I. Administrator will stand in the place of Employer in all dealings with the Company regarding premium billing and collection. 2. Employer designates Administrator as Employer's agent for all matters relating to the payment of premiums to and receipt of premium billings from the Company in connection with the insurance policies/certificates issued by the Company to Employer's employees. Employer authorizes the Company to recognize the Administrator as Employer's agent and to send all premium billings to Administrator on a schedule agreed to by the parties and the Company. 3. Administrator shall comply with all statutes and regulations of applicable jurisdictions relating to the registration and activities of administrators. 4. Administrator shall have no right to alter the provisions of the insurance policies/certificates issued by the Company to Employer's employees nor shall it bind the Company in any way without written consent of the Company. 5. Administrator may not assign its interest or delegate its duties under this agreement without the written consent of the Company. 6. The rights and duties of the Company and its individual policyholders/certificateholders with respect to each other under the policies/certificates shall not change or be affected by the terms of this Agreement. All policy/certificate provisions regarding premium payment, lapse and reinstatement shall remain the same regardless of the provisions of this Agreement. 7. The Company shall retain all rights to contact Employer directly at any time, and to contact insured employees at home at any time and at place of employment only with the Employer's permission. 8. Administrator shall have the following duties: a. Administrator shall remit all premiums due to the Company within 5 business days of receipt from the Employer. b. Administrator shall submit timely premium billings to Employer. c. Any premium refunds, or other payments submitted to Administrator by the Company for transmittal to policyholders/certificateholders shall be delivered within 5 business days of receipt by the Administrator. TWM-PCA-0905 Page 1 of 2

5 d. Administrator shall maintain adequate records of all transactions under this Agreement and it shall maintain any trust accounts or separate accounts required by state Iaw. Administrator may not commingle premiums received under this Agreement with funds in its general account. 9. This Agreement shall terminate upon the occurrence of the earliest of any of the following: a. Mutual agreement of the parties. b. Thirty (30) days written notice by any party to the other party. c. Administrator's mishandling of premium funds, embezzlement of funds or other violation of relevant statutes or regulations. d. The Company insures no employees of Employer. e. The bankruptcy, liquidation or cessation of business by any of the parties. 10. After termination of this Agreement, the Company may obtain from Administrator and Administrator shall provide upon request, information necessary to the conservation and continued processing of its business. 11. Employer and Administrator shall indemnify the Company and hold it harmless from all claims and liability arising from or related to the negligence or error of either Employer or Administrator in carrying out their obligations and duties with respect to the premium billings and premium payments which are the subject of this Agreement. 12. This Agreement shall be amended only by written agreement signed by the parties. Signed the day of,20 (Administrator signature) (please print name) (Administrator Business name and address) (Employer signature) (please print name and title) (Employer address) Received by the Company this day of, 20 The Company TWM-PCA-0905 Page 2 of 2 By: (Authorized Officer)

6 TransChoice Plus Administration Provided By: WEB-TPA P.O. Box 1808, Grapevine, TX First Application Add Dependents Certificate # Increase Coverage Certificate # Group Name LISH Hawaii Group Number Location Employee Spouse** Male Female Male Female Employee Enrollment Form Social Security No. Date of birth Date of marriage*** Social Security No. Date of birth Date of hire Avg hours worked per week Annual salary Occupation Employee ID Home address Work phone/ext. City State Zip code Home phone Child(ren) name Date of birth Gender Full time student Child(ren) name Date of birth Gender Full time student M F Yes No M F Yes No M F Yes No M F Yes No Primary Beneficiary: Relationship: Contingent Beneficiary: Relationship: Employee will be the beneficiary for any spouse** and/or child(ren) coverage TransChoice Plus Underwritten by Transamerica Life Insurance Company, Cedar Rapids, IA Plan I Monthly Premium Plan II Monthly Premium Employee Only $ $ Employee plus Spouse $ $ Employee plus Child(ren) $ $ Employee plus Family $ $ Is anyone proposed for coverage covered by any Title XIX program (e.g. Medicaid)? (Residents of KY or VA- do not answer.) Yes No If Yes, List name(s), who will be excluded from coverage. APPLICANT S STATEMENTS AND AGREEMENTS: I represent that all statements and answers made on or attached to this application are true to the best of my knowledge and belief, and realize that any false statements herein which materially affect the acceptance of the risk or the hazard assumed may result in loss of coverage under the policy/certificate to which this application is attached. All states except FL, LA, NJ, or VA- I understand that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (may be a crime and may subject such person to criminal and civil penalties in NC or OR). FL- I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. LA- I understand that any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NJ- I understand that any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. VA- I understand that any person who, with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing false or deceptive statements may have violated state law. I also understand that coverage will become effective only after all of the following conditions have been met: a) I must be a member of an eligible class of employees; b) I must have satisfied the employer waiting period; c) the employer group must have met the insurer s minimum participation requirement; d) I must satisfactorily answer all questions on this form; e) I must be actively at work, and for my dependents, they must not be disabled, on the effective date (according to the insurer s rules); and f) the first months premium must have been received by the underwriting company at its administrative office. Lastly, I understand that completion of this enrollment form in no way implies that I will be accepted for insurance coverage. Signed in (City/State) This Day of (Month/Year). Employee s Signature Spouse s** Signature (if applicable) Licensed Representative s Name Licensed Representative s Signature Agent # CCH-EF-02-LISH Page 1 of 1 **Spouse or equivalent, as defined by governing state law. ***Marriage or equivalent, as defined by governing state law.

7 Monthly Premium Agreement Thank you for enrolling in the Limited Benefit Medical Plan offered through your employer and LISH Hawaii. Your first month s premium payment will need to be made by check or money order made out to Imperia TPA. You will then have the option to make future payments by credit card or check or money order. Effective this day of, 2011, I agree to make my monthly premium payment no later than the 20 th of each month to pay for my Limited Benefit Medical Plan. I understand that if my payment is not received by the 20 th of each month, my coverage will be terminated and I will not be able to reinstate my policy until my employer s open enrollment period. Payment Options: Recurring Credit Card Payment (Complete the form below) You authorize regularly scheduled charges to your Visa, MasterCard, American Express or Discover card. Your card will be charged on the 20 th of each month for the total premium of the plan chosen on the TransChoice Plus Employee Enrollment Form. You agree that no prior notification will be provided. Credit Card Payment You can pay by credit card by visiting You can also call to make a payment over the phone. Coupon Booklet You can elect to have a coupon booklet mailed to you. You will then be responsible to mail a check or money order to Imperia TPA or use the credit card payment options above. Please complete the information below for Recurring Credit Card Payments: I authorize Imperia TPA to charge my credit card indicated below on the 20 th of each month for payment of my Limited Benefit Medical Plan. Billing Address: Phone# City, State, Zip: Account Type: Visa MasterCard Amex Discover Cardholder Name Account Number Expiration Date CVV (3 digit number on back of Visa/MC, 4 digits on front of AMEX) SIGNATURE DATE I authorize Imperia TPA to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form E. Camelback Road, Suite B-240 Phoenix, Arizona p f