X hits on this document

4 views

0 shares

0 downloads

0 comments

1 / 1

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.

Case Name

Date Submitted

Proposed Effective Date

Producer Name

Phone #

Fax #

New Business Case Information

General Agent Name

Phone #

Fax #

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?

Sole Proprietorship

Partnership

Does group coverage currently exist?

Corporation Yes No

Association

Professional Employer Organization

Other

_________

If Yes, indicate carrier

________________________

Effective Date

/

/

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?

Yes

No

What percentage of the cost of the plan will the employer contribute? Employee only ______

% Dependent

_____

%

BROKER SIGNATURE

DATE

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

Document info
Document views4
Page views4
Page last viewedWed Oct 26 09:31:49 UTC 2016
Pages1
Paragraphs67
Words535

Comments