EMPLOYER: RISK SCREENING FORM

RISK SCREENING FORM
Name of Prospect (Company Name):*
Contact Email*
example@example.com
Business Telephone No.:*

Area CodePhone Number
FAX

Area CodePhone Number
GENERAL PROSPECT INFORMATION
1. Type of Business:*
Number of years in business established:
2. Carrier/Plan Information
A. Has group been previously insured by Multicover/NetCare for Group Health?

YESNO
B. Name of current health insurance carrier:
How long w/ current carrier?
C. Reason for transfer:
D. Does your current medical plan include an extension of benefits provision for retirees or disabled employees and dependents upon cancellation?

YESNO
Details:
3. Employer Contribution/Rates:
A. Employer Contribution %
B. Medical Plan Name:

	Single $	Couple $	Family $
Current Rates

C. Dental Plan: $1,000 or $1,500 Max

	Single $	Couple $	Family $
Current Rates

ELIGIBILITY/ENROLLMENT INFORMATION
No. of Eligible Employees:
No. of Employees Covered:
No. of Employees in Waiting Period:
No. of Employees of COBRA:
No. of Part-Time Employees:
No. of Retired Employees Covered:
MEDICAL PROFILE
A. Has anyone been treated for a serious illness, been hospitalized or had surgery in the past 5 years? (e.g. Cancer, Diabetes, Cardiovascular Disease, AIDS, Asthma, Thyroid, Nervous System Disorders, Seizures, Substance Abuse, Renal Disease, Mental Illness, Kidney Stones)

YESNO
B. Has anyone had a claim of $5,000 or more in the past 12 months?

YESNO
C. Is anyone apt to have a continuing claim from an existing medical or physical disorder?

YESNO
D. Has anyone been advised to have surgery in the last six months, or anticipatehospitalization for any other reason?

YESNO
E. Are any of the employees or their dependents pregnant?

YESNO
If yes, how many
Expected Delivery Date
F. Have any employees missed 10 or more consecutive days of work in the past 12 months due to illness, injury or ongoing medical treatment?

YESNO
G. Are there any employees or dependents who are confined at home, incapacitated orconfined in a hospital or treatment facility?

YESNO
H. Are there any spouses or dependents who are not actively at work performing his or herduties full time due to illness, injury or ongoing medical treatment?

YESNO
I. Are there any employees or dependents not now insured who have ever been declinedfor life or medical coverage?

YESNO
J. Do any employees or dependents smoke cigarettes?

YESNO
If you have answered "YES" to any of these questions, please give details below:
The Applicant certifies that the information on this form is complete and true to the best of his/her knowledge. Groups employing 10 employees or less will be required to submit SWICA information and will be required to enroll 100% of eligible employees (unless they are covered under another health plan Should any information differ upon submission of enrollment applications, NetCare reserves the right to re-develop the rates or decline to cover the group.
Applicant's Signature:*

Clear
Title*
Date

MonthDayYear
Date
NetCare Life & Health Insurance Company Disclosure Notice
This Disclosure Notice is being provided to you as a resource and information about the policies and procedures of NetCare in connection with the offering of health insurance coverage.
Privacy Policy
Your privacy is very important to us, so at NetCare we carefully guard your confidential individual–personal identifiable information. Examples of personal identifiable information are your name, address, telephone number, e-mail address, social security number and date of birth. We place great importance on protecting your private information and handle this information in a confidential manner. We restrict access to non-public personal information about you to those employees who need to know that information for an appropriate reason, such as to provide products or services you requested or to administer benefits to you. In order to provide you with insurance benefits and services you want, we routinely collect, store and use information about our customers. We use this information for such activities as evaluating benefits, paying claims or administering our products and services and processing transactions requested by you.
Rates
NetCare will provide a rate proposal to you based on the census profile received. Should the actual enrollment differ from that information, NetCare reserves the right to redevelop the rates accordingly and/or decline to cover the group based on not meeting or complying with eligibility and/or participation requirements. NetCare also reserves the right to change premium rates based on demographic changes, utilization or loss experience, medical trend factors and/or benefit design changes.
Eligibility Requirements
An Individual is eligible for enrollment only if he or she resides in the service area (defined as Guam or the Commonwealth of the Northern Mariana Islands) and is a subscriber or immediate family member, and has not had coverage terminated for cause. Further, a subscriber is an individual who is a regular employee of a company of which this policy has been written under, and is working in the service are at least twenty (20) hours per week. This policy does not cover retired persons unless authorized by the Plan.
Service Area
Service area is defined as Guam or the Commonwealth of the Northern Mariana Islands.
Service Area Requirements
Coverage under this Policy is applicable to only those person(s) who maintain their principal residence in Guam, the CNMI, or where this Policy or applicable certificate is delivered and such persons must be physically residing in said jurisdiction during at least nine (9) months of each Contract Period while this Policy remains in force.
Participation Requirements
Groups enrolling 2 to 10 full-time employees must have 100% participation of eligible employees and 100% employer contribution of the single premium is required. Groups enrolling 11 to 49 full-time employees must have 80% participation of eligible employees and 70% employer contribution of the single premium is required. Groups enrolling 50 or more full-time employees must have 80% participation of eligible employees and 50% employer contribution of the single premium is required.
Renewal of Coverage
NetCare guarantees renewal of coverage upon the anniversary period of the group. A 60-day notice is generally provided prior to your renewal anniversary date. Your renewal premium rates may be changed due to your utilization or loss experience, medical trend factors, benefit design changes and demographic changes.
Benefits and Premiums
Benefit design plans as well as premium rates for specific benefit plans will be provided by NetCare to you upon the completion of a Census Data Profile. The benefits and premiums provided by NetCare are available for your group to select and for which your group is qualified to enroll. You are only allowed however, to choose or select one benefit plan design for the entire group.
Worker’s Compensation
Guam Public Law requires employers to provide worker’s compensation coverage to their employees. NetCare requires proof of worker’s compensation insurance upon enrollment. The name and policy number of your worker’s compensation carrier will be required in your Master Group Application. This is needed for potential third party liability claims.
Acknowledged by:*
Signature*

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Name of Company*
Date

MonthDayYear
Date
Marketing Agent:
Should be Empty:

RISK SCREENING FORM

GENERAL PROSPECT INFORMATION

ELIGIBILITY/ENROLLMENT INFORMATION

MEDICAL PROFILE

NetCare Life & Health Insurance Company Disclosure Notice

Privacy Policy

Rates

Eligibility Requirements

Service Area

Service Area Requirements

Participation Requirements

Renewal of Coverage

Benefits and Premiums

Worker’s Compensation