General Information
Stop-Loss Policy Beginning Date *
Stop-Loss Policy Beginning Date
The beginning date should be the new/renewal stop-loss policy effective date.
Stop-Loss Policy Ending Date *
Stop-Loss Policy Ending Date
The ending date should be the date the new/renewal stop-loss policy ends.
Members equals employees and dependents
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.
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$
$
Renewal Individual Stop-Loss (ISL) and Aggregate Stop-Loss (ASL) Coverage Details
ISL Coverages Included
Incurred / Paid
$
If there is a separate aggregating deductible, please enter it here. If no, please leave blank.
This is the sum of all separate lasered deductibles.
$
ASL Coverages Included
Incurred / Paid
$
$