Over 50 Employees

REQUIRED INFORMATION:

1. Name and complete address of employer. For multi-location employers, please list city, state and zip code of each location and number of employees at each.

2. Copies of current benefits for all group programs (copies of policies/booklets). Include medical, dental, life, LTD, STD, AD&D, business travel, voluntary benefits.

3. Anniversary date of plan(s).

4. Rate history for previous and current year and renewal rates if available.

5. Census of employees including the following information: name, date of birth or age, gender, home zip code and current covered dependent status (EE only, EE/SP, EE/CH, EE/FAM), annual or monthly earnings and occupation. Salary and occupation are needed for disability quotes.

6. Please denote COBRA participants on the census and include COBRA start date.

7. SIC code or description of your business.

8. Name of medical carriers and how long with each for past 5 years.

9. Amount of premiums paid by employer for each plan. List as a percentage of premium or dollar amount (for employees and dependents).

10. Copies of any paid claims reports for the last 24 months (36 months if available). Also, number of employees and dependents covered for the same claims period.

11. Any significant benefit changes during the last 3 years.

12. Large claims in excess of $10,000 over the past 24 months. Please provide diagnosis, prognosis, date of claim, detail on treatment received or pending and any current medications taken.

13. Details on any disabled persons or persons not actively at work.

If you have questions regarding this information or need help in gathering the information, please feel free to call us for assistance.

Longacre Financial Services, Inc.

6060 North Central Expressway, Suite 508
Dallas, TX 75206
Phone: 214.373.6380
Fax: 214.373.6240


	Š2004 Longacre Financial Services, Inc.