Group Information Form Failure to respond may result in your policy being canceled.

Transcription

1 Please answer questions using blue or black ink, in capital letters staying within the provided boxes. SECTION ONE GENERAL GROUP INFO 1. Group/Business name or DBA name (if applicable): 2. Legal entity name, if different than group name: 3. List owner(s) / partner(s): 4. List any commonly owned businesses (if applicable): 5. Tax Identification Number (EIN/TIN): 6. Group Number: Most group health plans are governed by ERISA with the exception of some religious organizations and government entities. If you are not governed by ERISA, please indicate: *Note: For more information about ERISA, please visit 7. Business physical address: Street Address: City: State: Zip: County: 8. Address of company headquarters (if different than physical address): Street Address: City: State: Zip: County: 9. Type of group sponsor (check one): Employer: Union: Trustees of Fund: Association: Other: 10. Organization type (check one): Private Corporation: Private Non-Incorporated: Nonprofit: Local Gov t: State Gov t: Church Group: Publicly Traded Organization: Trust: Other: 11. Does your company obtain health insurance coverage through a chamber / trust / association? Yes No C/T/A Name: 12. Indicate if company is organized as a: Parent: Subsidiary: Local Plant / Office / Division: Stand Alone: If applicable, provide related company info below: Company name: EIN/TIN: # Eligible: City: State: Zip: County: 13. How many hours per week must an employee work to be eligible for insurance? 14. Are the owners and their spouses the only people eligible for coverage? Yes No 15. Is there a group medical plan in place in addition to the products offered through Excellus BCBS? New York State of Health Other None 1 If so, what is the type of plan(s)? (ie: HMO, PPO, HDHP, etc) Number of individuals enrolled in this plan A nonprofit independent licensee of the Blue Cross Blue Shield Association

2 SECTION TWO REGULATORY EMPLOYER GROUP INFO 1. Number of owners and employees at all locations (all full time and part time employees): Avg. number for prior year Total number currently 2. Did you employ 20 or more employees who worked at least 20 weeks in the current year or prior year? Yes No 3. Do you employ any individuals enrolled in a union sponsored plan? Yes No If yes, please provide the number of such employees 4. Do you employ any Vermont residents who work at employer locations in Vermont, or are telecommuting from their home? Yes No If yes, please provide the number of such employees 5. Do you employ any out-of-state residents who work at out-of-state employer locations other than Vermont? Yes No If yes, please provide the number of such employees SECTION THREE 1. Eligibility Information a) Number of eligible employees and owners, working the minimum number of hours per week** Specific to Excellus BCBS All Other Locations and/or Plans* ELIGIBILITY GROUP INFO b) Number of retirees eligible for the employer group plan (do not count those eligible for Medicare eligible plan) c) Number of individuals enrolled in COBRA/New York continuation of coverage, and/or the young adult option d) Total Eligible (a+b+c) e) Eligible employees declining the group health insurance coverage (i.e. submitted valid waiver) N/A f) Net Eligible (d - e) g) Number of individuals enrolled or electing coverage h) Participation Percentage (g f x 100) 2. This document is being returned via: Fax Mail If your company offers a dental and/or Medicare plan through Excellus BCBS, please complete the appropriate supplemental form(s) including the employer contribution for these products. *This portion only to be completed if your company has multiple locations and/or multiple plans. Only include those eligible for health insurance with other insurance carriers that are not eligible to enroll in the Excellus BCBS plan. ** The minimum number hours for groups with 50 and under eligible employees is 20 hours, and 17.5 hours for groups with 51 or more eligible employees. 2

3 Group/Business Name: Instructions: Please enter the percentage of premium contributed by the employer towards the group health insurance. *Note: Be sure to fill out both sections, regardless of whether there are subscribers in each. If your group contributes a flat dollar amount, please calculate the percentage based on the respective section (i.e. Single, Family) premium amount and check the corresponding box. Below are the most commonly used contribution classes. Class Names A001 - All Active Employees A004 - Management A005 - Non-Management A008 - Full Time A009 - Part-Time R001 - Retired Non-Medicare Eligible A002 - Hourly A003 - Salaried A006 - Union A007 - Non-Union Z001 - Custom Class/Other R002 - Retired Medicare Eligible Employer Contribution Range - % (check applicable box for single tier and family tier) Single Class Name Product Class Name Product Class Name Product Family A nonprofit independent licensee of the Blue Cross Blue Shield Association EX-AGIF-LV Revision Date: 08/13/2014

4 Does your group contribute towards an /? Yes No If yes, please complete the section below: Product Type Employer Contribution Towards / Deductible - % Employer Contribution - $ Check One Class Name Product Check One Class Name Product Signature: The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete, including the number of persons proposed for coverage who work at least the minimum required hours per week. Employer Authorized Representative Signature Date Phone Number Print Name Address 4

5 Supplemental Form: Dental This section is not applicable Group/Business Name: Dental Information Eligibility Information a) Number of eligible employees and owners, working the minimum number of hours per week** b) Number of retirees eligible for the employer group plan c) Number of individuals enrolled in COBRA/New York continuation of coverage, and the young adult option d) Total Eligible (a+b+c) Specific to Excellus BCBS All Other Locations and/or Plans* e) Eligible employees declining the group dental insurance coverage (i.e. submitted valid waiver) N/A f) Net Eligible (d-e) g) Number of individuals enrolled or electing coverage in dental h) Participation Percentage (g f x 100) Are there any other dental plans in place for your group in addition to the products offered through Excellus BCBS? Yes No If so, what carrier is your company s dental coverage with? Number of individuals in this plan *This portion only to be completed if your company has multiple locations and/or multiple plans. Only include those eligible for health insurance with other insurance carriers that are not eligible to enroll in the Excellus BCBS plan. ** The minimum number hours for groups with 50 and under eligible employees is 20 hours, and 17.5 hours for groups with 51 or more eligible employees. A nonprofit independent licensee of the Blue Cross Blue Shield Association 5

6 Supplemental Form: Dental Failure to respond may result in your policy being cancelled. Class Names A001 - All Active Employees A002 - Hourly A003 - Salaried A004 - Management A005 - Non-Management A006 - Union A007 - Non-Union A008 - Full Time A009 - Part-Time Z001 - Custom Class/Other R001 - Retired Non-Medicare Eligible R002 - Retired Medicare Eligible Employer Contribution Range - % (check applicable box for single tier and family tier) Single Family Class Name Product Class Name Product Signature: The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete, including the number of persons proposed for coverage who work at least the minimum required hours per week. Employer Authorized Representative Signature Date Phone Number Print Name Address 6