Home
Who We Are
About Us
Who We Work With
Brokers & Consultants
Third Party Administrators
Insurance Carriers
What We Do
Medical Stop-Loss Insurance Services
Self-Funded Health Plan Consulting Services
SL Advisor 3.0 - Stop Loss Optimization and Decision Support Tool
Alternative Risk Transfer Solutions
Resource Center
Self-Funding 101
Contact
Home
Who We Are
About Us
Who We Work With
Brokers & Consultants
Third Party Administrators
Insurance Carriers
What We Do
Medical Stop-Loss Insurance Services
Self-Funded Health Plan Consulting Services
SL Advisor 3.0 - Stop Loss Optimization and Decision Support Tool
Alternative Risk Transfer Solutions
Resource Center
Self-Funding 101
Contact
General Information
Account Name
*
Stop-Loss Policy Beginning Date
*
Stop-Loss Policy Beginning Date
The beginning date should be the new/renewal stop-loss policy effective date.
MM
DD
YYYY
Stop-Loss Policy Ending Date
*
Stop-Loss Policy Ending Date
The ending date should be the date the new/renewal stop-loss policy ends.
MM
DD
YYYY
Number of Employees
*
Number of Members
*
Members equals employees and dependents
Plan Annual Maximum
*
None
$1,000,000
$1,500,000
$2,000,000
$2,500,000
Other
Projected Plan Claims Per Employee Per Year
*
The projected plan claims per employee per year should include the same coverages as covered on the stop-loss policy (i.e. medical and prescription drug). The projected plan claims cost should be on a mature basis. If you have any questions about the projected claims calcultion, please contact Strategic Benefit Resources.
$
Information About Any Known Claimants
If there are known claimants that are expected to generate claims in excess of the ISL deductible, if available, please provide the expected claims for each of the known claimants and we can account for these claimants in the modeling. If there are no known claimants or the expected claims for the known claimants is not available, please leave blank.
Projected Claims for Known Claimant 1
$
Projected Claims for Known Claimant 2
$
Projected Claims for Known Claimant 3
$
Renewal Individual Stop-Loss (ISL) and Aggregate Stop-Loss (ASL) Coverage Details
Stop-Loss Insurance Company Name
ISL Coverages Included
Medical
Rx
Dental
Vision
ISL Contract Basis
Incurred / Paid
Paid
12/12
12/15
12/18
12/24
12/36
15/12
18/12
24/12
36/12
ISL Deductible
ISL Monthly Premium Rate (Composite Per Employee Per Month)
$
ISL Aggregating Deductible
If there is a separate aggregating deductible, please enter it here. If no, please leave blank.
ISL Maximum Reimbursement
Unlimited
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
ISL Number of Separate Lasered Claimants
ISL Sum of Separate Lasered Deductibles
This is the sum of all separate lasered deductibles.
$
ASL Coverages Included
Medical
Rx
Dental
Vision
ASL Contract Basis
Incurred / Paid
Paid
12/12
12/15
12/18
12/24
12/36
15/12
18/12
24/12
36/12
ASL Aggregate Claim Corridor
*
125%
110%
115%
120%
ASL Monthly Premium Rate (Composite Per Employee Per Month)
$
ASL Monthly Attachment Factor (Composite Per Employee Per Month)
$
Thank you!
