Thanks for your interest in the RepCare Program. Reading the material below will expedite the over-all process of providing quotations and moving towards the underwriting and enrollment process. Please answer ALL questions accurately and completely for the quickest and most accurate response. EMPLOYEES: Current group insurance rules require that you list all full-time, payroll employees on your census form, even if they have medical coverage elsewhere. Please identify any employee who is covered elsewhere (i.e., through a spouse at another employer). Every full-time, payroll employee is required to complete an enrollment form, including health history questions, even though that employee is "waiving" coverage due to coverage elsewhere. VERIFICATION: A copy of your firm?s most recent Quarterly State Wage and Tax Contribution Report will be required with your application and enrollment for coverage. Any employee on the census who is not on the Quarterly Report or any employee on the Quarterly Report who is not on the census will cause a delay in underwriting and approval. LOCATION: If more than 10% of your employees live and work out of the state in which your firm is headquartered, please understand that this may limit the number of insurance providers available. EFFECTIVE DATE: The process of getting quotes and completing enrollment and application forms, as well as the underwriting process by the carrier, have stretched out, and it is currently taking between 4 and 6 weeks, after all enrollment and application forms are received, for coverage to become effective. Please do not cancel your current medical plan coverage until a written acceptance by the new carrier has been received. Start this RFQ and enrollment process at least 2 months before you expect to change carriers. REQUEST FOR GROUP MEDICAL INSURANCE PROPOSAL/QUOTE Association Affiliation: Select One AIM/R ERA HIRA MAFSI MANA NEMRA NIRA OPRA PTRA SEMAA Name and title of contact person completing this form:   Employer Name: Address: City: State: select oneAlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces AmericasArmed Forces EuropeArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarianas IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: Tel: Fax: email: CENSUS FORM: Please list all full-time, payroll employees of your firm, even if covered elsewhere. Employee 1 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 2 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 3 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 4 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 5 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 6 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 7 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 8 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 9 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 10 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 11 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Employee 12 Name: Age: Residence ZIP: Dependent Status: ---- Select One ---- Single Children Only Spouse Only Full Family Waiving Coverage: yes no Current Medical Carrier: How Long? Renewal Rates: Employee:  /month Family:  /month Requested Effective Date for New Carrier: Does your Firm share the cost of insurance with your employees? yes no Benefits Requested: PPO MSA Other:  PPO CoPay: $10 $20 $30 Deductible: $250 $500 $1000 $2000 Other  CoInsurance: 90% 80% Other  Stop Loss Limit: $2500 $5000 $10,000 Supplemental Accident: $300 $500 Maternity: yes no RX Card: yes no If yes, which RX CoPay: $10/$20/$30 $15/$30/$40 Other  Are there any other benefits or benefit levels that you want us to quote? Also quote on Group Life Dental Personal Accident Life-time Disability Medical/Health History Summary To expedite getting you an accurate quote, as soon as possible, please answer the following questions about the employees of your firm. In the past 5 years, have you, any of your employees or any of the eligible dependents of your employees been diagnosed with or treated for: AIDS or AIDS related complex (ARC) High Blood Pressure Alcohol or Drug Abuse Hodgkin's Disease Alzheimer's Disease Kidney Disease Cancer/Tumor(s)/Cyst(s)/Growths Liver Disease Diabetes Stroke Heart or Circulatory Condition Crohn's Disease Leukemia, Hemophilia, or other blood disease or disorder Mental or Nervous Disorder Colitis A disease or disorder of muscles, joints, bones, affecting muscle control If your answer to any of these above conditions is YES, please explain below: 1. In the past 5 years, have you, or any of your employees or any of the eligible dependents of your employees had surgery or a medical claim over $5000.00? yes no If yes, please explain below: 2. Do you, any of your employees or any of the eligible dependents of any eligible employees have any treatment, hospitalization or surgery pending that has not been completed? yes no If yes, please explain below: 3. Are you, any of your employees or any of the eligible dependents of any eligible employees currently pregnant? yes no If yes, please explain below: 4. Are you, any of your employees or any of the eligible dependents of any eligible employee at home due to a disability or wheel chair confined or do they have a dependent that is considered developmentally disabled or handicapped in any way? yes no If yes, please explain below: