Employer General Health Questionnaire
CBIZ PEO & Association Consulting ServicesMaster Distributor of the Health Benefit Alliance Partnership Program. This Employer Health Questionnaire is utilized to assist in the assessment of the risk associated with underwriting your group. You acknowledge that you will answer these question honestly and to the best of your knowledge. *All fields must be completed or the GHQ will be rejected.
Name of Practice
*
Number of Employees to be offered health insurance:
*
Number of Employees currently enrolled in your health insurance:
*
Nature of Business
*
Group City, State
*
Name of Referring Broker:
1. I will answer the following questions for all plan participants and dependents to be covered under this health insurance coverage to the best of my knowledge.
*
Yes, I agree.
No
If No, please explain below:
2. Has anyone missed more than five consecutive workdays in the last 12 months due to injury or illness by them or their dependents?
*
Yes
No
If Yes, please explain below:
3. Has anyone been treated in the past five years or anticipate being treated for a serious illness, immune system disorder, hemophilia, cancer, heart disorder/disease, Hepatitis C, kidney, or organ or tissue disorder/transplant, stroke, AIDS/ARC, mental or nervous disorder, substance abuse or other accident/injury?
*
Yes
No
If Yes, please explain below:
4. Are there other known potential Shock Loss Claims and/or have any plan participant (employee or dependents) incurred $10,000 or more in accident and/or health and Rx claims within the last 12 months? Shock losses are defined on the Potentially Catastrophic Diagnosis and High-Cost Drug listing page. The diagnosis and high-cost drug lists (see attached on page 3) are intended to help the Proposed Insured identify potential catastrophic claims.
*
Yes
No
If Yes, please explain below:
5. Are there any employees, spouses or dependents who are disabled, or confined in a hospital or treatment facility, or have been pre-certified within the last three months to have an upcoming procedure or treatment, or any employees who are on leave of absence to care for a dependent who will be a plan participant of this health plan? For employees, disabled means absent from work and/or on leave of absence or Family and Medical Leave Act FMLA benefits due to his or her medical condition; for dependents, disabled means unable to perform his or her normal functions of a person of like age.
*
Yes
No
If Yes, please explain below:
6. Has anyone within the last six months been advised to have surgery or does anyone anticipate hospitalization or treatment/outpatient procedure for any other reason?
*
Yes
No
If Yes, please explain below:
7. Are there any employees who are not performing his or her normal duties due to illness or injury?
*
Yes
No
If Yes, please explain below:
8. Are any employees or their dependents pregnant and/or considered to be high risk for complications of pregnancy, or carrying multiple fetuses?
*
Yes
No
If Yes, please explain below:
I affirm I have answered all questions to the best of my knowledge.
Company Name
*
Employer Plan Sponsor-Responsible Party Printed Name
*
Position
*
Date
*
-
Month
-
Day
Year
Date
Employer Plan Sponsor Email Address:
*
example@example.com
Employer Plan Sponsor Phone Number
*
Please enter a valid phone number.
Employer Plan Sponsor-Responsible Party Signature
*
Clear
Insurance Broker's Name
Insurance Broker's Email
example@example.com
Please return to your CBIZ Master Distributor Representative for submission for Underwriting Review/Approval. No group is authorized for consideration for the Health Benefit Alliance Program without approval of this Group Health Questionnaire.
Submit
Should be Empty: