Austin Small Business Owners Benefits Program

Transcription

1 Austin Small Business Owners Benefits Program Administered by:

2 Small businesses and PPACA: Did you know that employers with 50 or less full-time employees are not required to provide minimum essential health care coverage for these employees and are not subject to a penalty? At the same time, many employees won t be covered by echange subsidies so the decision to offer health coverage is still the right choice for employers who want to attract and retain quality workers. Small Business Solutions from Ternian SBU HealthBasic Have you been unable to provide health benefits in the past due to the high cost of major medical coverage? Are you concerned about being unable to meet participation requirements? Are you unable to contribute significantly to offset premiums for your employees? HealthBasic includes an employer-paid Accident and Assistance plan that is available at less than $15 month employee. After an employer purchases this base plan, employees are then eligible to buy-up to additional coverage for their every medical epenses. In fact, it takes just minutes to get everyone enrolled since there is no census or health history required. You ll need just 10 enrollees to initate coverage! HealthValu Are your medical premiums rising to unaffordable levels? Have you decided that you can t continue to offer major medical coverage? Have you been cancelled due to lack of participation? HealthValu is for businesses that have offered major medical in the past, but need a more affordable solution. HealthValu plans offer fied indemnity and accident benefits that help employees cover every medical epenses and yet premiums are 25-40% less than major medical coverage. These plans require an employer contribution that is typically lower than major medical contribution requirements. LEARN MORE

3 Small Business Solutions from Ternian SBU HealthBasic Employers pay for a base plan of accident/assistance coverage, allowing employees to purchase additional health coverage at affordable rates. Step 1: By paying just $14.90 month employee, employers can provide the HealthBasic Accident and Assistance Plan: $10,000 in accidental medical coverage $10,000 in accidental death coverage Unlimited 24/7 access to a doctor for consultations via the Consult-A-Doctor telemedicine program A prescription discount plan for savings at retail pharmacies nationwide Unlimited access to a 24/7 Employee Assistance Program Three in-son counselor visits Step 2: After this basic package is offered, employees can choose to buy one of three additional levels of coverage that offers provider office visit pre-pays, inpatient and outpatient benefits as well as prescription discounts and copay options. These limited-benefit medical plans start at just $80 a month for an individual and dental coverage is also available. HealthBasic plans offer affordable rates and standardized pricing. No quote request or medical questionnaires are needed. HealthValu Help with the most common, every medical epenses at 25-40% less than major medical coverage. HeathValu plans offer fied indemnity and accident benefits that help employees cover their every medical epenses. The benefits include provider office visit pre-pays of just $10 as well as coverage for prescriptions, lab work, -rays and diagnostic testing. In case of more serious illnesses or accidents, HealthValu also offers total potential in-hospital benefits of $35,000 to $75,000. HealthValu is an ideal option for small businesses that can no longer afford the cost of major medical coverage, but want to provide more benefits than what are typically included in a limited-benefit medical plan. We just need a census, copy of current major medical plan, and we can provide you with a quote. If you want to to find out more about how these these plans plans can can help help you you offer offer affordable affordable health coverage to your employees, health coverage to your employees, contact or contact These limited medical plans do not meet what PPACA describes as minimum essential benefits.

4 HealthBasic - A simple solution for your health coverage needs HealthBasic can fit the needs of all kinds of small employers, from restaurants, retail, construction, automotive and more. Because we know that small businesses don t have a lot of time to dedicate to managing employee benefits, HealthBasic offers hassle-free administration. In fact, it takes just minutes to get everyone enrolled since there is no census or health history required. With a low employer contribution of $14.90 month, all employees will receive the HealthBasic Accident & Assistance Plan. Then, employees and business owners will have the opportunity to buy-up to HealthBasic Voluntary Medical plans HealthBasic Accident & Assistance Plan Employer Paid Outpatient Accident Medical Up to $10,000 Paid at 80% of actual charges - $100 deductible occurrence Accidental Death & Dismemberment $10,000 Consult A Doctor Telemedicine Unlimited physician telephone consultations - $38 fee for a diagnosis requiring a prescription Employee Assistance Plan Unlimited counselor telephone consultations + three face to face sessions R Discount Card Discounts on Generic & Brand Name Prescriptions via ScriptSave Monthly Rates 100% Employer Contribution Required $14.90 (1)The Outpatient Accidental-Only and AD&D Benefit Plans are underwritten by AXIS Insurance Company. Dependents also receive these benefits when enrolled in a HealthBasic buy-up plan!

5 HealthBasic Voluntary Medical Plans Provides limited medical coverage for accidents, illness and specified disease to help cover basic, minor-medical epenses. INPATIENT (1) BASIC CHOICE OWNER LEVEL Hospital Confinement - Day 1 benefit amount $1,000 1 $2,000 1 $4, Days 2+ benefit amount $500 thereafter $1,000 thereafter $2,000 thereafter Maimum Benefit 5 s 5 s 20 s - Days 1+ additional ICU benefit amount N/A $750 5 s $1,000 5 s Surgery benefit amount (incl. maternity) surgery $1,000 1 surgery $2,000 1 surgery $4,000 1 surgery Anesthesia benefit amount - surgery 25% surgical amount 25% surgical amount 25% surgical amount OUTPATIENT (1) Physician Office Visit Pre-pay (2) $10 $10 $10 - Benefit amount visit $65 10 visits $85 5 visits $ visits - Wellness benefit amount visit N/A $125 1 visit $200 1 visit - Well child care (up to age 4) benefit amount visit N/A $100 4 visits $125 4 visits Accident maimum benefit amount up to: Included in Included in Included in - Benefit % payable Accident & Assistance Accident & Assistance Accident & Assistance Deductible Accident Plan Plan Plan Emergency Room (sickness) benefit amount visit $200 1 visits $500 1 visits $750 1 visit Surgery benefit amount surgery N/A $1,000 1 surgery $2,000 1 surgery Anesthesia benefit amount - surgery N/A 25% surgical amount 25% surgical amount Diagnostic, X-ray, Lab - benefit amount test: - Class I: Laboratory - Blood work, CMP, Lipid Panel $25 2 tests $30 2 tests $30 4 tests - Class II: X-ray, ECG, Pap/PSA tests, all other diagnostic $75 2 tests $100 2 tests $125 2 tests - Class III: Ultrasound, Mammogram $125 1 test $150 1 test $200 1 test - Class IV: CT, PET, MRI $250 1 test $400 1 test $750 1 test PRESCRIPTION (3) - Retail - Generic RX copay $10 $10 $10 - Retail - Preferred Brand RX copay Discount Only $20 $30 - Mail Order - Generic RX copay $30 $30 $30 - Mail Order - Preferred Brand RX copay Discount Only $90 $90 Monthly benefit maimum INDIVIDUAL $200 $100 $200 CRITICAL ILLNESS/ AD&D/ LIFE Critical Illness (1) benefit amount payable for 10 conditions N/A $1,500 $10,000 Accidental Death & Dismemberment (1) benefit amount* Included in Accident & Assistance Plan OTHER SERVICES (5) Consult a Doctor: Telephonic Doctor Office Visits - $38 Included in Accident & Assistance Plan New Directions Behavioral Health: EAP Included in Accident & Assistance Plan PHCS PPO Discounts Yes Yes Yes Monthly Rates - Voluntary Employee Only $80.40 $ $ Employee + 1 $ $ $ Family $ $ $ (1)The Fied Indemnity, Outpatient Accidental-Only, Critical Illness and AD&D Benefit Plans are underwritten by AXIS Insurance Company. (2) The office visit pre-pay is a service through the PHCS PPO Network. (3) The prescription copay is underwritten by Companion Life Insurance Company. (4) Term Life is underwritten by Minnesota Life. (5) These services are not and are not provided by the underwriting companies shown here. *Benefit amounts listed are for: Employee/Spouse/Child(ren)

6 HealthValu Provides a higher level of limited medical coverage for accidents, illness and specified disease to help cover basic, minormedical epenses. HealthValu is available for groups who want more for their employees. HealthValu represents a great choice for groups who can t afford major medical plans, but want a benefit package that is more comprehensive than HealthBasic. HealthValu requires 100% Employer Contribution. INPATIENT (1) ASBA CHOICE ASBA ADVANTAGE Hospital Confinement - Day 1 benefit amount $2,250 1 $3, Days 2+ benefit amount $1,000 thereafter $1,500 thereafter Maimum Benefit 15 s Plan Year 15 s Plan Year - Days 1+ additional ICU benefit amount $1,000 5 s $1,500 5 s Surgery benefit amount (incl. maternity) surgery $1,250 2 surgeries $1,500 2 surgeries Anesthesia benefit amount - surgery 25% of surgical amount 25% of surgical amount OUTPATIENT (1) Physician Office Visit Pre-pay (2) $10 $10 - Benefit amount visit $85 10 visits $ visits - Wellness benefit amount visit $85 1 visit $100 1 visit - Well child care (up to age 4) benefit amount visit $85 4 visits $100 4 visits Accident maimum benefit amount up to: $10,000 $10,000 - Benefit % payable 80% U&C 80% U&C Deductible Accident $0 $0 Emergency Room (sickness) benefit amount visit $500 2 visits $650 2 visits Surgery benefit amount surgery $1,000 1 surgery $1,250 1 surgery Anesthesia benefit amount - surgery 25% of surgical amount 25% of surgical amount Diagnostic, X-ray, Lab - benefit amount test: - Class I: Laboratory - Blood work, CMP, Lipid Panel $30 4 tests $30 6 tests - Class II: X-ray, ECG, Pap/PSA tests, all other diagnostic $75 2 tests $75 4 tests - Class III: Ultrasound, Mammogram $150 1 test $150 2 tests - Class IV: CT, PET, MRI $500 1 test $750 1 test PRESCRIPTION (3) - Retail - Generic RX copay $10 $10 - Retail - Preferred Brand RX copay $30 $20 - Mail Order - Generic RX copay $30 $30 - Mail Order - Preferred Brand RX copay $90 $60 Monthly benefit maimum INDIVIDUAL $200 $250 CRITICAL ILLNESS / AD&D Critical Illness (1) benefit amount payable for 10 conditions $10,000 $15,000 Accidental Death & Dismemberment (1) benefit amount* $20,000/10,000/1,000 $25,000/10,000/1,000 OTHER SERVICES (5) Consult a Doctor: Telephonic Doctor Visits - $38 Fee Yes Yes New Directions Behavioral Health: EAP Yes Yes PHCS PPO Network Discounts Yes Yes Monthly Rates 100% Employer Contribution Required Employee Only $ $ Employee + 1 $ $ Family $ $ (1)The Fied Indemnity, Outpatient Accidental-Only, Critical Illness and AD&D Benefit Plans are underwritten by AXIS Insurance Company. (2) The office visit pre-pay is a service through the PHCS PPO Network. (3) The prescription copay is underwritten by Companion Life Insurance Company. (4) Term Life is underwritten by Minnesota Life. (5) These services are not and are not provided by the underwriting companies shown here. *Benefit amounts listed are for: Employee/Spouse/Child(ren)

7 HealthAssist Gap Coverage A supplemental gap plan for employer groups with employees who are already insured by a high-deductible health plan. Provides first-dollar fied indemnity coverage to help employees with out-of-pocket medical deductibles and co. HEALTHASSIST BASIC HEALTHASSIST PLUS HEALTHASSIST MAX INPATIENT (1) Hospital Confinement benefit amount - Day 1 benefit amount $1,000 $1,500 $2,500 - Day 2+ benefit amount $500 $750 $1,000 Hospital Maimum Benefit 4 s Plan Year 6 s Plan Year 8 s Plan Year OUTPATIENT (1) Benefit Amount, up to $2,500 $5,000 $10,000 - Benefit % payable 100% U&C 100% U&C 100% U&C ACCIDENTAL DEATH & DISMEMBERMENT (1) Benefit Amount, up to* $2,500/1,000/1,000 $5,000/2,500/1,000 $10,000/5,000/1,000 CRITICAL ILLNESS (1) Benefit Amount -Payable for 10 conditions: Cancer, Heart Attack, Renal Failure, Stroke, Major Organ Transplant, Multiple Sclerosis, Coronary Artery Bypass Surgery, Alzheimer s, ALS, Terminal Illness. Monthly Rates Employee $2,500 $23.12 $5,000 $37.08 $10,000 $51.31 Employee +1 $50.87 $81.58 $ Family $73.99 $ $ (1)The Fied Indemnity, Outpatient Accidental-Only, Critical Illness and AD&D Benefit Plans are underwritten by AXIS Insurance Company. *Benefit amounts listed for: Employee/Spouse/Child(ren). Available on a voluntary basis for members who are already insured on an HDHP OR HSA COMPATIBLE health plan.

8 Dependent Coverage A solution for the quiet crisis in healthcare Dependent A solution for the quiet crisis in healthcare Coverage A solution for the quiet crisis in healthcare Introducing affordable dependent coverage that can fill Introducing affordable dependent coverage that can fill a significant gap in the marketplace Introducing significant affordable gap in the dependent marketplace coverage coverage that can that fillcan fill a significant gap gap in in the the marketplace There is a dependent coverage crisis facing our nation. The cost of major medical coverage for There dependents is a dependent continues coverage to rise eponentially. crisis facing At our the nation. same time, The cost employers of major are medical forced to coverage allocate for their dependents There major medical continues is a dependent contributions to rise coverage to eponentially. employee-only At the crisis facing our coverage same time, nation. The and cost reduce employers of major dependent are forced medical contributions to allocate coverage for to their major dependents avoid carrier medical continues participation contributions to rise penalties to employee-only eponentially. and offset coverage At the the same impact and time, of reduce a dependent contributions to employers tough economic are forced climate. to allocate their avoid carrier participation penalties and offset the impact of a tough economic climate. major medical contributions to employee-only coverage and reduce dependent contributions to avoid If you think carrier PPACA participation is going so penalties solve this and problem, offset the think impact again. of If a dependents tough economic are offered climate. major medical If coveragethrough you think PPACA an is employer even going so solve this if it s problem, not affordable they think again. If dependents cannot purchase are offered subsidized major coverage medical coveragethrough employer even if it s not affordable they cannot purchase subsidized coverage If you think health PPACA is going echanges. so solve this problem, think again. If dependents are offered major medical through health echanges. coveragethrough an employer even if it s not affordable they cannot purchase subsidized coverage through That s why That s why health SBU SBU is offering is offering echanges. affordable limited medical coverage for employees enrolled in their affordable limited medical coverage for employees enrolled in their employer s major medical plan who cannot afford family coverage. In addition, these plans will employer s major medical plan who cannot afford family coverage. In addition, these plans will That s help cover why the SBU out-of-pocket is offering affordable costs for limited employees medical enrolled coverage in a high for employees deductible enrolled plan. in their help cover the out-of-pocket costs for employees enrolled in a high deductible plan. employer s major medical plan who cannot afford family coverage. In addition, these plans will help cover the out-of-pocket costs for employees enrolled in a high deductible plan. Best of all, the average cost of these plans is approimately 50-70% less than major medical. Best of all, the average cost of these plans is approimately 50-70% less than major medical. Best of all, the average cost of these plans is approimately 50-70% less than major medical. Review the sample plan scenario below to learn more: Review the sample plan scenario below to learn more: An employer currently offers major medical coverage with a $1,000 deductible. The employer An contributes Review employer the 80% currently sample to employee-only offers plan major scenario premiums. medical below coverage Below to learn are with the a more: current $1,000 costs deductible. for employees: The employer contributes 80% to employee-only premiums. Below are the current costs for employees: An employer currently offers major medical coverage with a $1,000 deductible. The employer EE contributes 80% to employee-only premiums. Only EE+Spouse EE Only Below are the current EE+Family EE+Spouse costs for employees: EE+Family PREMIUM $400 $850 $1,200 PREMIUM $400 $850 $1,200 EMPLOYEE COST EE $80 Only EE+Spouse $530 EE+Family $880 EMPLOYEE COST $80 $530 $880 PREMIUM $400 $850 $1,200 EMPLOYEE COST $80 $530 $880

9 Dependent Coverage Plan Dependent Coverage Plan Dependent Coverage Plan In addition to these premiums, the family will also face potentially Austin Small high Business out-of-pocket Member Benefits Program costs In because addition of to the these plan s premiums, deductible. the Realizing family will that also these face costs potentially are not high sustainable out-of-pocket for the costs In because average addition worker, of to the these plan s premiums, employer deductible. decides the Realizing family to work will that also with these face SBU costs potentially to develop are not high sustainable a solution. out-of-pocket As for a the result, costs because average SBU develops worker, of the the plan s the following employer deductible. customized decides Realizing to plan work that offerings: with these SBU costs to develop are not sustainable a solution. As for a the result, average SBU develops worker, the the following employer customized decides to plan work offerings: with SBU to develop a solution. As a result, SBU develops Supplemental the following customized coverage plan for offerings: employees to help with the out-of-pocket PART A: Supplemental deductible and co coverage from their for employees employer-sponsored to help with major the out-of-pocket medical plan. PART A: deductible and co from their employer-sponsored major medical plan. PART Supplemental coverage for employees to help with the out-of-pocket EMPLOYEE A: A: COVERAGE deductible and co from their employer-sponsored major medical plan. EMPLOYEE Outpatient Accident COVERAGE Coverage $2,500 EMPLOYEE Outpatient Inpatient Benefit Accident COVERAGE Coverage $2,500 ($500/ $2,500 for 5 s) Outpatient Inpatient Critical Illness Benefit Accident Benefit Coverage $2,500 ($500/ $2,500 for 5 s) Inpatient Critical Accidental Illness Benefit Death Benefit & Dismemberment $2,500 ($500/ $2,500 $5,000 for 5 s) Critical Accidental Illness Death Benefit & Dismemberment $2,500 $5,000 Accidental Death & Dismemberment $5,000 PART B: Two options to choose from for affordable Dependent Coverage. PART B: Two options to choose from for affordable Dependent Coverage. PART B: Two options to choose from for affordable Dependent Coverage. DEPENDENT COVERAGE PLAN 1 - BASIC PLAN 2 - CHOICE DEPENDENT INPATIENT BENEFIT COVERAGE (1) PLAN 1 - BASIC PLAN 2 - CHOICE DEPENDENT INPATIENT Day 1 - Hospital BENEFIT Confinement COVERAGE Benefit $1,000 1 $2,000 1 PLAN 1 - BASIC PLAN 2 - CHOICE Day Days Hospital Hospital Confinement Confinement Benefit Benefit $600 $1, s/ 1 $1,250 $2, s/ 1 INPATIENT Days 2+ Hospital BENEFIT Confinement (1) Benefit ICU $600 $ s/ s/ ICU $1,250 $ s/ s/ Day Surgery 1 - Hospital benefit amount Confinement (incl. maternity) Benefit ICU $600 $1,000 N/A 5 s/ 1 ICU $750 $2,000 $1,000 5 s/ 1 Days Surgery OUTPATIENT 2+ benefit Hospital ILLNESS amount Confinement (incl. BENEFIT maternity) Benefit $600 N/A 10 s/ $1,250 $1, s/ 1 OUTPATIENT Benefit amount ILLNESS visit BENEFIT ICU $600 s/ ICU $750 s/ Surgery (incl. maternity) $ N/A $1,000 Benefit Wellness amount benefit amount visit visit $100 $ s $100 $ s OUTPATIENT Wellness Accident maimum benefit ILLNESS amount benefit BENEFIT visit up (1) to: $2,500 $100 (at 1 80%) $5,000 $100 (at 1 80%) Benefit Accident Emergency amount maimum Room (sickness) visit benefit benefit up amount to: visit $2,500 $275 $75 5 (at 2 s 80%) $5,000 $350 $75 5 (at 2 s 80%) Wellness Emergency Surgery benefit Room amount (sickness) surgery benefit visit amount visit $275 $100 N/A 21 s $350 $100 $ s Accident Surgery Diagnostic, benefit maimum -ray, amount lab benefit - benefit surgery amount up to: test $2, % N/A schedule (at 80%) $5,000 $ % schedule (at 1 80%) Emergency Diagnostic, PRESCRIPTION Room -ray, (sickness) BENEFIT lab - benefit benefit amount amount test visit $100 $ % month schedule 2 member s $200 $ % month schedule 2 member s Surgery PRESCRIPTION CRITICAL benefit ILLNESS amount BENEFIT BENEFIT surgery $100 month N/A member $200 $500 month 1 member Diagnostic, -ray, lab - benefit amount test 100% schedule 100% schedule CRITICAL (one occurence) ILLNESS for 10 BENEFIT conditions PRESCRIPTION BENEFIT $1,000 $5,000 $100 month member $200 month member (one ACCIDENTAL occurence) DEATH for 10 & conditions DISMEMBERMENT BENEFIT $10,000 $1,000 $20,000 $5,000 CRITICAL ACCIDENTAL OTHER SERVICES ILLNESS DEATH & BENEFIT DISMEMBERMENT (1) BENEFIT $10,000 $20,000 (one occurence) for 10 conditions $1,000 $5,000 OTHER Consult a SERVICES Doctor (Telephonic Doctor Office Visits $38), ACCIDENTAL DEATH & DISMEMBERMENT BENEFIT $10,000 YES $20,000 YES Consult EAP, PHCS a Doctor PPO Discounts (Telephonic Doctor Office Visits $38), OTHER EAP, PHCS SERVICES YES YES (1) The Fied Indemnity, PPO Discounts Outpatient Accidental-Only, Critical Illness and AD&D Benefit Plans are underwritten by AXIS Insurance Company. (2) The office visit Consult a Doctor (Telephonic Doctor Office Visits $38), (1) YES YES EAP, The pre-pay Fied PHCS Indemnity, is a service PPO Discounts Outpatient through the Accidental-Only, PHCS PPO Network. Critical The Illness prescription and AD&D copay Benefit is underwritten Plans are underwritten by Companion by AXIS Life Insurance Insurance Company. Company. (2) Term The Life office is visit underwritten pre-pay is by a service Minnesota through Life. the These PHCS PPO services Network. are not (3) The prescription and copay are not is underwritten provided by the by Companion underwriting Life companies Insurance Company. shown here. (4) Term Life is (1) underwritten The Fied Indemnity, by Minnesota Outpatient Life. (5) Accidental-Only, These services Critical are not Illness and AD&D and are Benefit not provided Plans are by underwritten the underwriting by AXIS companies Insurance shown Company. here. (2) The office visit pre-pay is a service through the PHCS PPO Network. (3) The prescription copay is underwritten by Companion Life Insurance Company. (4) Term Life is underwritten by Minnesota Life. (5) These services are not NOTICE and are not provided by the underwriting companies shown here. The described in this document provides limited benefits. Limited NOTICE benefits plans are products with reduced benefits intended to The supplement comprehensive described in this health document provides plans. This limited benefits. is not Limited an alternative benefits to plans comprehensive are coverage. products It with does reduced not provide benefits major intended medical or to supplement comprehensive comprehensive medical coverage health and is not plans. designed This to replace major is not NOTICE an medical alternative. to comprehensive Further, this coverage. It is does not not minimum provide essential major medical benefits or The comprehensive as set forth under described medical the Patient coverage in this Protection document and is and not provides Affordable designed limited to Care replace benefits. Act. major Limited medical benefits. plans are Further, this products is with not reduced minimum benefits essential intended benefits to supplement as set forth under comprehensive the Patient health Protection and plans. Affordable This Care Act. is not an alternative to comprehensive coverage. It does not provide major medical or TRN-DCKIT comprehensive medical coverage and is not designed to replace major medical. Further, this is not minimum essential benefits as TRN-DCKIT set forth under the Patient Protection and Affordable Care Act. TRN-DCKIT

10 Dependent Coverage Plan Austin Small Business Member Benefits Program In addition to the SBU plan cost savings shown below, the employee benefits from a valuable supplemental plan to help them with high out-of-pocket costs from their own major medical plan. EMPLOYEE COST COMPARISON Entire Family Major Medical $880 EE Major Medical + Family SBU Basic* $407 EE Major Medical + Family SBU Choice* $609 In a fect world, all families would have access to major medical coverage. In reality, employers and their employees need other options that will allow them to select coverage that meets their budget. *Includes employee, spouse plus two children for rate comparison purposes. Dependent Coverage is a limited medical plan underwritten by AXIS Insurance Company. It is not considered creditable, coverage under HIPAA, is not major medical, and is NOT designed to replace, provide, or modify major medical. This information is a brief description of the important features of the plan. It is not a contract of. The terms and conditions of coverage are set forth in the policy issued in the state in which policy is delivered. The policy is subject to the laws of the state in which it is issued. Coverage may not be available in all states or certain terms may be different if required by state law. This does not apply to the etent that trade or economic sanctions or regulations prohibit us from providing, including, but not limited to, the payment of claim. TRN-DCKIT To To find out more about how SBU s Ternian s affordable dependent plans can meet these needs, contact us to at at or or info@sbua.org info@.com

11 Dependent Coverage REQUEST FOR QUOTE FORM IMPORTANT INFORMATION Please submit the following information to start the process. COMPANY INFORMATION: Business Name: Business Type: SIC Code: Situs State: List States Where Employees Reside: PROGRAM INFORMATION: Attach a copy of current Major Medical Plan Design and pricing (Include employer contribution breakout and final cost to employee by tier) Total # eligible # Enrolled by tier: EE EE/SP EE/CH FAMILY Attach Census (if available) Average Age % of female population % of employee turnover Premium/Billing Admin: Payroll Deduct EDI File Transfers Payroll Deduct List Bill Proposed Effective Date: / / PROGRAM PRODUCER INFORMATION: Agent Name: Phone: Agency Name: Broker of Record: YES NO Comments/ Additional Information: TRN-DCKIT PLEASE PLEASE SUBMIT SUBMIT COMPLETED FORM FORM AND ATTACHMENT INFORMATION TO YOUR TO YOUR SUB TERNIAN REPRESENATIVE REPRESENTATIVE OR FAX FAX OR OR COMPLETED COMPLETED FORM TO: FORM TO: marketing@.com info@sbua.org QUESTIONS? Call QUESTIONS? Call