Aetna U.S. Healthcare Small Business Center 841 Prudential Drive, 6th Fl West, F602 Jacksonville, FL 32207 Phone 1-800-223-2125 Fax 1-800-814-5677
CONTRACTUAL VALIDATION FORM DELAWARE HMO/QPOS (One - Nine) Eligible Lives
This form must accompany all new case submissions. All information must be submitted 30 days prior to the effective date to ensure ID cards are received prior to effective date.
Proposed Effective Date
New Business Case Information
General Agent Name
If any of the information listed below is excluded or incomplete when the case is submitted, all materials will be returned to the producer for completion.
Required documentation for new business case installation: Employer master application Employee individual application Employer Verification Form Note: must be signed by employer. Employee Waiver of Coverage Form (If Applicable) If company is a one life group provide the following:
Schedule C along with Schedule SE
1120S with a Schedule K
Form 1065 with a Schedule K
If the above are not available please provide:
Articles of Incorporation
Certificate of Existence or Incorporation
Corporate By-Laws, or an application for an EIN#
If currently covered under a group plan, provide a copy of recent prior carrier bill. Individuals on the bill should match those listed on the wage and tax statement. If prior coverage is not currently in place, please display financial stability by providing documentation such as bank statements (most recent and 6 months prior) in company’s name and/or a line of credit Copy of most recent calendar year wage and tax statement containing the names, salaries, etc. of all employees of the employer group. Employees who have terminated and work part time must be noted Copy of rate quote(s) including:
Complete proposal including rate and plan design
Employer signature on signable rate page and supporting rate documentation
Rates must match the enrollment reported and effective date. If discrepancy exists please include documentation to support the
discrepancy COPY of binder check and completed Binder Submission Form.
Send originals to address on form.
Broker of Record letter and commission forms
Additional Information: To whom will the Aetna US Healthcare contract be issued?
Does group coverage currently exist?
Corporation Yes No
Professional Employer Organization
If Yes, indicate carrier
At any time has the group been covered under an Aetna US HealthCare plan (or affiliated company such as Prudential Healthcare)?
If yes, provide coverage dates: From Yes Total eligible lives No to . ____________ _______________ ________ How many employees are enrolled in the current employer sponsored medical plan; or if no prior coverage exists, how many employees are likely to enroll in this plan? __________ How many eligible employees are not expected to enroll because they have spousal or individual coverage? _____
Do all eligible employees work 25 hours or more?
What percentage of the cost of the plan will the employer contribute? Employee only ______
INTERNAL ONLY Vendor #, If known:
HMO License Expiration Date:
Payee Name: Life and Health License Expiration Date:
Payee SSN# or TIN#:
Ed. 02/16/2001 Delaware