Stop Loss Quote Request Form

Stop Loss Quote Request

# of Enrolled Employees

Type of Current Plan

Current Rates/Renewal Rates (FI or SF)

STOP LOSS: Specific Deductible

(Example: (NA, $50K, $75K, $100K)

Specific and Aggregate Contract Basis

(Example: 24/12, 12/18)
(Example: Unlimited)
(Example: Unlimited)
Benefits covered under Specific Benefits
Benefits covered under Aggregate
Include Mo. Aggregate Accommodation?
Include Terminal Liability Option (TLO)?
Include NNL/Rate Cap?
(No New Laser)
Include No GAP Option?

Current Lasers?

(Full RBP, RBP/Physician Network, Dual Option)

Special Plan Design Assumptions

Claims Data Requirements

  • Current/Renewal rates and fees
  • Current stop loss contract
  • Current Census, including DOB, Gender, Home Zip Code, Contract, Current Plan enrollment
  • Aggregate report (medical and Rx claims SL reimbursements, fixed costs, etc.)
  • 50% report (thru current date)
  • Pre-Cert reports (thru current date)
  • Large claim report with LCM Notes for the current and previous contract year
  • Top 10 Rx claimants by dollar amounts paid (thru current date)
  • Pending claims report (thru current date)
  • Denied claims report (thru current date)
  • Requested plan design

If you have any questions, please contact Nate Ogden,