RFP and GHQ (AllSetPEO)

DATE

Date

What's your Company Name?

Enter your Company's Legal Name.

What's your Tax ID Number?

Enter your Tax ID / FEIN number.

What's your Company Address?

Street Address

Street Address Line 2

CityState

Zip Code

Fulladdress

Please Provide a Description of your Business Operations.

What is your website?

Company Incorporation Type

What would you like quoted?

Company Incorporation Type

What is your motivation to change providers?

What are your States of Operation?

Where do you have employees at.

How many Full-Time Employees do you have?

How many Part-Time Employees do you have?

Do you currently use a PEO?

Who's your current PEO?

PEO Admin Fee

What is your average annual payroll?

Who's your Current Payroll Provider?

Monthly Admin Cost for Payroll Vendor (USD)

What is your current Payroll Cycle?

Current Benefit Provider

Benefit Contribution Rate

Benefit Renewal Month

Who's your Workers' Comp provider?

AIG, State Fund, etc.

When's your Workers' Comp renew?

Enter the month.

Do employees handle hazardous materials?

If yes, please list all the materials

Do you have company-owned vehicles and drivers?

What is your maximum mile radius?

Owner or Member Info:

Ownership Information Needed. No investor info is necessary. If your company is 100% owned by investors just skip.

Only include those who are involved in day-to-day business operations. Only list individuals with ≥5% ownership

Rows	Owner Name	Title	Is on payroll?
1
2
3
4

IsOwnerName1onpayrol1

IsOwnerName1onpayrol2

IsOwnerName1onpayrol3

IsOwnerName1onpayrol4

Do any owners own more than 50% of a separate entity?

If yes, please list Ownership and Entity details

Do more than 5% of your employees work offshore, work in foreign countries, or travel to foreign countries on business?

If yes, please provide details

Do you anticipate any layoffs in the next 12 months?

Are you aware of any active complaints that may result in a claim against the company?

If yes, please provide details

What's your Name?

First NameLast Name

What's your Work Email?

youremail@example.com

Fullname

What's your Title?

What's your Phone Number?

Please enter a valid phone number.Format: (000) 000-0000.

To complete, please sign below. By signing below, you agree to Dinsmore/Steele's Terms and Conditions.

Sign below

Please input your signature in the box

DATE

Date

Date Signed

Date

Hour MinutesAM/PM Option

DATE

Date

SIC or NAICS Code

Which States do you have physical locations

Has your company ever been denied a health insurance quote from an insurance carrier, a reinsurance company, or a PEO?

Please explain

Are there any current participants in COBRA / State Continuation?

A. List any current participants in COBRA / State Continuation (use additional paper if necessary):

Rows	Name of Individual	COBRA/Continuation Effective Date	Date of Birth	Zip Code
1
2
3
4
5

Has anyone who was enrolled in medical coverage been terminated in the past 60 days?

B. List down details

Rows	Name of Individual	Date of Birth	Zip Code
1
2
3
4
5

Is anyone currently disabled?

Are there any employees and/or dependents who are on the health plan that are disabled?

C. List any employees and/or dependents who are on the health plan that are disabled:

Rows	Name	Disability	Qualifying Event
1
2
3
4
5

Next, please answer the following questions on behalf of your company to the best of your knowledge. It is not necessary to transfer information from Personal Health Questionnaires. You may include additional sheets for detailed explanations.

GENERAL ILLNESS QUESTIONS:

Rows	To the best of your knowledge Yes	To the best of your knowledge No
Has anyone been treated for a serious illness, been hospitalized or had surgery in the past 5 years?
Is anyone currently hospitalized, confined at home incapacitated, confined in a treatment facility, incapable of self-support because of physical or mental disability?
Has anyone been advised that medical treatment, diagnostic testing, surgery or hospitalization is necessary?

Has anyone had a serious illness, hospitalized, or had surgery in the past 5 years?

Has anyone been advised that medical treatment, diagnostic testing, surgery or hospitalization is necessary?

Is anyone currently hospitalized, confined at home, incapacitated, confined in a treatment facility, incapable of self-support because of physical or mental disability?

Has anyone had a serious illness, hospitalized, or had surgery in the past 5 years?

Has anyone been advised that medical treatment, diagnostic testing, surgery or hospitalization is necessary?

Is anyone currently hospitalized, confined at home, incapacitated, confined in a treatment facility, incapable of self-support because of physical or mental disability?

SPECIFIC ILLNESS QUESTIONS: Is anyone currently being treated or been advised to seek treatment for any of the following?

Please Select all that apply:

Please Select all that apply(alwaysempty):

List

Rows	Name	Sex	DOB	Condition	Date of Onset	Last Date Treated	Treatment/Drug	Degree of Recovery
1
2
3

IS ANYONE CURRENTLY PREGNANT?

If yes, please provide due date and note below if normal, high risk, multiple births, or preterm labor with this pregnancy.

(This includes employees, dependents, and/or COBRA participants.)

Rows	Name	Due Date	Type of Pregnancy or Condition (normal, high risk, preterm labor, etc.)
1
2
3

uploadtext

{uploadtext}

If you need to upload more than five documents, please consider creating a zip file for easier uploading.

Additional File Upload 1

Additional File Upload 2

Additional File Upload 3

Additional File Upload 4

I certify that the statements herein are true and correct to the best of my knowledge. I understand that this form is used for information only and does not bind coverage. I will notify the entity collecting this information of any changes that occur after signing this Group Health Questionnaire and prior to implementing health coverage.

In the event that material information has been omitted or is inaccurate, the service agreement may be terminated for breach. In such cases, my company may be liable to Milliman or an employee for damages.

This information is gathered for statistical and actuarial use only. This information is not to be used in connection with any decisions or actions regarding an individual's employment.

Authorized Signature

Please input your signature in the box

Print Name

Title

Date Signed

Date

CLIENT PRIVACY NOTIFICATION

Thank you for completing the requested information above. Any non-public personal information (i.e. Name with address and/or social security number, and detail health information (protected health information) that you provide via hard copy or through the Milliman, Inc. HERO Online Data Collection Website will be used solely for the purpose of providing risk assessment that will provide a health insurance quote to the employer. Milliman is acting as a Business Associate to the PEO/MEWA/Association/Trust and is subject to certain provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. Milliman will not sell, license, transmit or disclose this information outside of Milliman unless: a) necessary for Milliman to provide the services on behalf of our PEO partner providers, b) expressly authorized by you, c) necessary for backup documentation purposes, or d) required by law.

Please verify that you are human

Company Incorporation Type

Type a question

RFP Intake

Owner or Member Info:

General Health Questions

CLOSING