Group Health Questionnaire (page 1 of 5)
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- Sibyl Parks
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1 Group Health Questionnaire (page 1 of 5) This questionnaire must be filled out completely. Please be sure to indicate None if applicable. Sample will not accept the questionnaire if incomplete. Use additional paper if necessary. Date Proposed Effective Date: I. COMPANY AND CURRENT ENROLLMENT INFORMATION Company Street Address City State Zip County Total Number of employees on payroll: Benefits Contact & Phone # Total Full Time: Total Part Time: Total Number of employees currently enrolled in health care plan: Are any health plan enrollees NOT paid employees (other than spouses or children)? ***If yes, please provide names and details: Current Health Carrier: Health Carrier Renewal Date: / / Is your current Plan Self-Funded? No Don t Know ***If yes, please provide claims. Are you currently with a PEO? If yes, name of PEO: Any ineligible class of employees If yes, which class: Yes Please provide a complete description of your business operation: SIC Code: Number of Locations: Please identify all states of operation: Page 1 of 5
2 Group Health Questionnaire (page 2 of 5) A. List any current participants in COBRA / State Continuation (use additional paper if necessary): COBRA / Continuation Activating Event / Date of Individual Effective Date (i.e. employee termination, etc.) B. List any participants currently eligible for COBRA who have not yet elected coverage and/or any participants who will become eligible for COBRA to the Health Plan effective date (use additional paper if necessary): Date Eligible Activating Event/Date C. List any employees and/or dependents who are on the health plan that are disabled: Disability Qualifying Event Page 2 of 5
3 Group Health Questionnaire (page 3 of 5) II. RATE HISTORY (if more than 3 plans, include the 3 most popularly-elected plans) Plan 1 : Plan 2 : Plan 3 : III CURRENT PLAN BENEFIT SUMMARY INFORMATION (Individual, in-network only) Current Plan s: 1: 2: 3: Current Plan Types: Annual Deductible Co-Insurance (as %) Out-of-Pocket Max (excluding deductible) Office Visit Copay Prescription Drug Copay generic / brand formulary / brand non-formulary / / / / / / IV. CURRENT PLAN CONTRIBUTION INFORMATION Employee Only Employee + Spouse Company Contribution Levels (by $ or %) Employee + Child Family Attach a copy of your benefit summary for each plan and year listed above. Include carrier claims report if available. Page 3 of 5
4 Group Health Questionnaire (page 4 of 5) Next, please answer the following questions on behalf of your company to the best of your knowledge. It is not necessary to transfer information from Personal Health Questionnaires. You may include additional sheets for detailed explanations. GENERAL ILLNESS QUESTIONS: a) Has anyone been treated for a serious illness, been hospitalized or had surgery in the past 5 years? b) Is anyone currently hospitalized, confined at home, incapacitated, confined in a treatment facility, incapable of self-support because of physical or mental disability? To the Best of My Knowledge (any or all): YES NO c) Has anyone been advised that medical treatment, diagnostic testing, surgery or hospitalization is necessary? (If yes to any or all, please provide details in the table below.) SPECIFIC ILLNESS QUESTION: Is anyone currently being treated or been advised to seek treatment for any of the following? Please check all that apply: AIDS or testing HIV Positive arthritis back disorder cancer diabetes heart disease kidney disorder liver disease mental illness muscular disorder nervous system disorders respiratory disease stroke substance dependency transplants tumor other serious conditions (If any boxes are checked, please provide details in the table below.) Sex Date of Birth Condition Date of Onset Last Date Treated Treatment/Drug Degree of Recovery Page 4 of 5
5 Group Health Questionnaire (page 5 of 5) Known Medical Conditions to the best of your knowledge (continued): IS ANYONE CURRENTLY PREGNANT? If yes, please provide due date and note below if normal, high risk, multiple birth, or preterm labor with this pregnancy. To the Best of My Knowledge: This includes employees, dependents or COBRA participants. YES NO Due Date Type of Pregnancy or Condition (normal, high risk, preterm labor, etc.) I certify that the statements herein are true and correct to the best of my knowledge. I understand that this form is used for information only and does not bind coverage. I will notify the entity collecting this information of any changes that occur after signing this Group Health Questionnaire and to implementing health coverage. In the event that material information has been omitted or is inaccurate, the service agreement may be terminated for breach. In such cases, my company may be liable to Milliman or an employee for damages. This information is gathered for statistical and actuarial use only. This information is not to be used in connection with any decisions or actions regarding any individual's employment. In compliance with requirements for GINA, the entity collecting this information is not requesting genetic information. No information regarding the height or weight of any Michigan employees has been provided. Authorized Signature Title Date Print Print of Company Broker / Sales Signature Broker / Sales Print Date Client Privacy Notification Thank you for completing the requested information above. Any non-public person information (i.e. with address and/or social security number, and detail health information (protected health information) that you provide via hard copy or through the Milliman, Inc. HERO Online Data Collection Website will be used solely for the purpose of providing risk assessment to the Professional Employer Organization (PEO), Multiple Employer Welfare Arrangement (MEWA), association group (Association) or Trust that will provide a health insurance quote to the employer. Milliman is acting as a Business Associate to the PEO/MEWA/Association/Trust and is subject to certain provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) regulations. Milliman will not sell, license, transmit or disclose this information outside of Milliman unless: a) necessary for Milliman to provide the services on behalf of the PEO/MEWA/Association/Trust, b) expressly authorized by you, c) necessary for backup documentation purposes, or d) required by law. Page 5 of 5
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