PECAA HP Benefits Request

Group Health Questionnaire

This Group Health Questionnaire is utilized to assist in the assessment of the risk associated with your group and whether it is a good fit for this program.

You acknowledge that you will answer these questions truthfully, completely, following reasonable commercial effort, and to the best of your knowledge. This form may be used and shared with all vendors of the Program. This form will also be shared with other vendors outside of the Program that service the group health plans implemented for your group through the Program, including but not limited to insurance and/or reinsurance carriers. To the extent that this form is relied upon by these vendors, false or misleading statements could adversely impact the services provided as well as trigger termination rights. To the extent this form is separately used or analyzed by an insurance company, additional legal or contractual consequences, including, but not limited to, a loss of coverage or denial of coverage may occur.

Name of Practice*

Practice Street Address*

Suite/Office Number

City*

State*

Zip Code*

Practice Main Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Nature of Business*

EIN Number*

# of Employees currently enrolled in health coverage

# of Employees currently enrolled in health coverage*

# of Employees to be offered health coverage

# of Employees to be offered health coverage*

Average age of Employees to be offered health coverage*

Name of Referring Broker

1. I will answer the following questions for all plan participants and dependents who may be covered under this healthcare coverage (referred to as “anyone” throughout the rest of this questionnaire) truthfully, completely, following reasonable commercial effort, and to the best of my knowledge.*

Yes, I agree.No (If no, please explain below or in Appendix as needed.)

1. b*

2. Have you sponsored a health plan before? If so, please list the carriers/third party administrators you have worked with over the past three (3) years.*