First Name
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Last Name
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Phone
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Please enter a valid phone number.
E-mail
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If Applicable, Brokerage Name and Location
Organization Name Requesting Audit
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Organization Key Contact Name
Organization Location (City, State)
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Please provide general information about your plan.
Last Time Your Organization Performed a Verification?
Is your Plan...
Self Funded
Fully Insured
Is Your Enrollment...
Active
Passive
What Percentage of Your Participants Enroll On-Line vs Paper Submission?
What is the Name of Your Benefits Administrator or the Name of Your In-House Benefit Administration System?
Are any Documents Collected When New Dependents are Added to the Plan Throughout the Year?
Yes
No
When is Your Medical Plan Renewal Date?
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Please provide general information about your plan.
Total Number of Employees
Total Number of Employees Enrolled in the Medical Plan
Total Number of Employees That Cover at Least One Dependent (child or spouse)
*
Total Number of Dependent Spouses
Total Number of Dependent Children
Average Annual Cost Per Dependent
Average Overall Medical Expense (all members)
Average Annual Turnover Rate (%)
Estimated Date the Audit will Begin
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If a working spouse rule - such as a spouse surcharge or carve out/exclusion is in place - please provide the following information:
Describe the Working Spouse Rule in Place or Being Considered
Total Number of Spouses Enrolled in the Medical Plan(s)
Total Number of Spouses Participating in the Rule
Average Annual Cost per Spousal Dependent
If a Surcharge, What is the Monthly Rate Charged to the Employee
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