Document 6536767

1. Employee Census Information
All eligible employees must be listed on the census. Please refer to the detailed census
information on the example below. (Note: The employee census spreadsheet must be submitted
electronically. Please e-mail census information to [email protected] or
[email protected]. Submit below-formatted Excel spreadsheet to avoid
processing delays.
Sample of Census Information
(please submit census in formatted Excel spreadsheet as shown.)
Last Name
First Name
Rubble
Barney
Plan
Type
POS
TIER
DOB
GENDER
ZIP
Family
11/11/1970
F
20859
2. Current Carrier Information
Provide copies of the following:
 Current Health Insurance Carrier(s)
 Current and Renewal Plan Design(s) and Benefits on carrier letterhead
 Current Rates and Renewal Rates (up to 2 years) on carrier letterhead
 If available, but required for 100+: Claims and Enrollment experience and
high claimant info, to include amount, status, and diagnosis
(Note: If any of the above is missing, this will delay the processing of your quote.
Please include any additional documentation available to assist underwriting.)
3. Large Group Employer Risk Appraisal Questionnaire (RAQ)
Complete and sign the attached three (3)-page questionnaire.
4. Submit a Quote Request
The above documents must be submitted by email:
[email protected] for Maryland
OR
[email protected] for Delaware
5. Broker name _________________ and commission percentage ___ %.
Provide Broker name and commission percentage (%) above. (Maximum percentage
allowed is 5.00%)
Large Group Quote Checklist rev. 08.11
Page 1 of 1
© 2011 Coventry Health Care of Delaware, Inc.
Employer Risk
Appraisal Questionnaire
CHCDE/CHL – 1001.2 – RAQ
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Employer Risk Appraisal
Questionnaire
51 + Eligible Employees
This questionnaire is designed to provide information specific to your group and will be used by Coventry Health
Care of Delaware, Inc./Coventry Health and Life Insurance Company (CHCDE/CHL) in evaluating the risk
characteristics to more accurately establish rates, benefits, and eligibility rules as part of your application for
coverage. Please choose one company:  Coventry Health Care of Delaware  Coventry Health and Life
Insurance Company
I.
GENERAL INFORMATION
Company Name
Company Address
City/State/Zip
Phone Number
Requested Effective Date
Nature of Business & SIC
Years in Operation
Reason Out to Bid
Please list any employer locations other than noted above.
II.
GROUP ELIGIBILITY
Total Employees
Full-time
Part Time
Total Eligible for Coverage
Total Waivers
Retiree
COBRA
Please see your CHCDE/CHL rate proposal for complete eligibility and quoting policies.
Please identify on census or attach a list of all:
 COBRA: former employees and/or dependents covered or eligible to receive coverage under state or COBRA
continuation. Please list employees’ termination date.
 Retirees: if eligible for coverage with CHCDE/CHL
 Out of Area employees/members applying for coverage with CHCDE/CHL.
Employer Contribution:
Employee
Dependent
Waiting Period
Are all eligible employees covered by Workers’ Compensation?  Yes  No
If no, please explain:
III. COVERAGE INFORMATION (List all health carriers in the last three years)
Carrier
RATES
Effective Date
Employee
Reason for Change
EE/Spouse
EE/Child(ren)
Family
Current
$
$
$
$
Renewal
$
$
$
$
Plan Description*
*Please attach a current benefit summary(s) for the most recent 2-year period.
Previously covered by CHCDE/CHL? Yes No
CHCDE/CHL – 1001.2 – RAQ
If Yes, date covered: ____________________
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IV.
HEALTH INFORMATION
Provide the answers to the following questions as they pertain to all eligible employees and/or covered dependents
(including COBRA, any state continuation programs, and eligible retirees).
A. To your knowledge has any person (employee and/or employee’s dependents, or COBRA individuals) to be
covered been diagnosed or treated by a provider for any of the following conditions within the last 5 years?
(Please check Yes or No. If yes, please circle all conditions that apply.)
1. Alcohol or substance abuse
 Yes
 No
No # of people: ______
2. Arthritis
 Yes
 No
No # of people: ______
3. Asthma, emphysema, cystic fibrosis, or other lung disease
 Yes
 No
No # of people: ______
4. Diabetes: Type (if known)______________
 Yes
 No
No # of people: ______
5. Cancer
 Yes
 No
No # of people: ______
6. Epilepsy/seizure disorder
 Yes
 No
No # of people: ______
7. Disorder of the spine, back, joints, bones
 Yes
 No
No # of people: ______
8. High blood pressure
 Yes
 No
No # of people: ______
9. Heart disease
 Yes
 No
No # of people: ______
10. Stroke, paralysis
 Yes
 No
No # of people: ______
11. Kidney or bladder disease, kidney dialysis
 Yes
 No
No # of people: ______
12. Liver disease or hepatitis: Type (if known)______________
 Yes
 No
No # of people: ______
13. Multiple sclerosis, muscular dystrophy, or cerebral palsy
 Yes
 No
No # of people: ______
14. Psychological or other mental disorder
 Yes
 No
No # of people: ______
15. Organ transplant (planned or past)
 Yes
 No
No # of people: ______
16. HIV/AIDS
 Yes
 No
No # of people: ______
17. Tuberculosis
 Yes
 No
No # of people: ______
18. Colitis or Crohn’s disease
 Yes
 No
No # of people: ______
19. Any condition or disease not mentioned above, or
anticipated surgery
 Yes
 No
No # of people: ______
For each item checked “YES,” please explain in section D on the back of this page.
B. Have any employees, dependents, or COBRA individuals who are eligible for coverage incurred claims that
have exceeded $10,000 (medical and/or pharmacy) during the last 12 months?
 Yes  No
Please explain in section D.
Are any employees currently disabled or otherwise not actively-at-work? (Give medical details and
date disability started.)
 Yes___________________________________________________________  No
C. Are any eligible employees or dependents currently pregnant?
 Yes
How many? ____ Ages _________ Due Dates ___________________
CHCDE/CHL – 1001.2 – RAQ
 No
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D. Please explain any “YES” answers in this space. Please indicate what question you are answering. If more
space is needed, attach a separate sheet. Please sign and date all attachments.
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V.
STATEMENT OF UNDERSTANDING
I understand and do hereby certify that the information contained in this Employer Risk Appraisal Questionnaire is
complete and accurate to the best of my knowledge. I further certify that I hold a position with the company that permits
me to have the information necessary to complete this Employer Risk Appraisal Questionnaire on behalf of the
company or I have conferred with and confirmed my answers with person(s) that hold such position(s) with the
company. It is further understood that CHCDE/CHL reserves the right to re-rate or rescind coverage if any supplied
information is an intentional misrepresentation of a material fact.
I understand that CHCDE/CHL may contact employees and dependents to obtain additional follow-up information. I
agree to inform employees that CHCDE/CHL may contact them in order to obtain additional information or to discuss
information provided on this form. Employer agrees to indemnify CHCDE/CHL for any liability or damages resulting from
any breach of representation made in this form and for claims brought by employees and their dependents regarding
the use of the information disclosed by employer.
Signature: _________________________________
Print Name: ___________________________
(Company Executive or Senior Human Resources employee)
Title:
Phone Number: _______________________________
____________________________________
Date Signed: ______________________________
Broker Name (Print): ____________________________
Broker Signature: _______________________________
CHCDE/CHL – 1001.2 – RAQ
Date of Broker Signature: ____________________
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