Stop Loss Insurance Brokers | Health Reinsurance | Health Insurance Stop Loss | SA Benefit Services

Please complete the Request for Proposal
Submission Checklist Form

FIRST NAME: *
   
LAST NAME: *

EMAIL ADDRESS: *
   
PHONE: *

NAME OF THE EMPLOYER: *
   
GROUP CITY: *

GROUP STATE: *
   
GROUP ZIP CODE: *

DESIRED EFFECTIVE DATE OF COVERAGE: *
of ,
QUOTE DUE DATE: *
of ,
QUOTE DUE DATE TIME: *
   
SPECIFIC DEDUCTIBLE (CURRENT): *

SPECIFIC DEDUCTIBLE (PROPOSED): *
   
CONTRACT TYPE (CURRENT): *

CONTRACT TYPE (PROPOSED): *
   
NATURE OF BUSINESS AND/OR SIC CODE: *

CURRENT STOP LOSS CARRIER NAME: *

ANCILLARY COVERAGE’S REQUESTED: *





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Once we receive your information, we will contact you. The following information needs to be submitted secure to RFP@sabenefitservices.com
    •    Current census (including dob, sex, type of coverage, zip code, and plan elected. Identify
         Retiree, COBRA, and Active status.)
    •    Schedule of current benefits and proposed benefits
    •    Identify any proposed plan changes for upcoming renewal
    •    Monthly paid medical and/or rx claims and enrollment counts for the current plan year and last 2 plan years
         (enrollment and claim paid amounts must be broken down by month)
    •    Shock claims in excess of 50% of the current deductible and any serious ongoing
         condition including diagnosis/prognosis (Current plan year and last 2 plan years)
    •    Trigger Report (Current plan year and last 2 plan years)
    •    CM notes for current large claimants, if available