Data Required to Quote

A. Client Information:

1. Name of Prospect
2. Address of Prospect
3. Location of divisions/subsidiaries to be covered
4. Nature of the business (what, specifically to be covered)
5. Standard Industrial Classification Number-SIC Code

B. General Information:

1. Census data showing gender, date of birth, and single/family designation
2. Specific and Aggregate deductibles requested
3. Date the quote is needed and the renewal date of the Plan

C. Benefit Information:

1. Copy of Employee Booklet/Schedule of Benefits/ Summary Plan Description

D. Experience Information: (If Available)

1. Month-by-month claims paid listing, including number of employees/dependents for the last 2 policy years, for Medical, RX, and Dental coverage.
2. Current Specific and Aggregate Stop Loss levels.

E. Additional Shock Loss Information:

1. Are there any individuals with a serious disease (e.g. diabetes, cancer, heart disease, AIDS, etc.)?
2. Shock Loss information for each period cited in #E1 above. Claims in excess of 50% of the specific Stop-Loss Level.
   
   For Claims that exceed 50% of the Specific Stop-Loss Level the reinsurance markets need name of the claimant (employee/dependent), date(s) of loss, amount, cause, status, prognosis and diagnosis of each claim if possible. Case management reports are helpful, if they are available.
3. Cobra covered persons.