PECAA Employer GHQ

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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:
Group Main Address:
Nature of Business:
# of Employees currently enrolled in 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.

Yes (If yes, please explain below.)No
2. b
3. What percentage of eligible participants and dependents smoke, vape, or use tobacco products.
4. Does anyone use illegal drugs or substances (including, even if legal in your local jurisdiction, cannabis products)? If so, please add an explanation of the number or percentage of eligible participants and dependents who use illegal drugs or substances, including cannabis products.

Yes (If yes, please explain below or in Appendix as needed.)No
4. b
5. Has anyone missed more than five consecutive workdays in the last 12 months due to injury or illness by them or their dependents?

Yes (If yes, please explain below or in Appendix as needed.)No
5. b
6. 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 (If yes, please explain below or in Appendix as needed.)No
6. b
7. Does anyone have any known potential medical issues such that anyone has incurred or is anticipated to incur $10,000 or more in accident and/or health or prescription drug claims or costs within the last twelve (12) months or anticipated over the next twelve (12) months? To assist in responding to this question, please see the Potentially Catastrophic Diagnosis and High Cost Drug listing page. This page is intended to help you accurately complete this questionnaire.

Yes (If yes, please explain below or in Appendix as needed.)No
7. b
8. Is anyone, or is anyone anticipated to become, disabled, confined in a hospital or treatment facility, certified/re-certified within the last three (3) months to have an upcoming procedure or treatment?

Yes (If yes, please explain below or in Appendix as needed.)No
8. b
9. Is anyone on a leave of absence to care for a dependent? If so, will either the caretaker or the dependent be eligible to participate in this health plan? (For employees, “disabled” means absent from work, on leave of absence, or Family and Medical Leave Act (“FMLA”) benefits due to said employee’s medical condition. For dependents, “disabled” means unable to perform his or her normal functions of a person of like age.)

Yes (If yes, please explain below or in Appendix as needed.)No
9. b
10. Has anyone within the last six (6) months been advised to have surgery or does anyone anticipate hospitalization or an outpatient surgical procedure?

Yes (If yes, please explain below or in Appendix as needed.)No
10. b
11. Are there any employees who are not performing or are anticipated over the next twelve (12) months to become unable to perform his or her normal duties due to illness or injury?

Yes (If yes, please explain below or in Appendix as needed.)No
11. b
12. Is anyone now or anticipated to become pregnant, considered to be at high risk for complications of pregnancy, or carrying multiple fetuses?

Yes (If yes, please explain below or in Appendix as needed.)No
12. b
13. Is anyone receiving treatment and/or medical services related to a worker’s compensation claim? If so, please note in the explanation both the treatment/medical services and whether that claim is in dispute or is anticipated to be denied/not classified as a worker’s compensation claim now or in the next twelve (12) months.

Yes (If yes, please explain below or in Appendix as needed.)No
13. b
I affirm I have answered all questions to the best of my knowledge.
Company Name
Employer Plan Sponsor-Responsible Party Printed Name
Employer Plan Sponsor-Responsible Party Printed Name

First NameLast Name
Position
Employer Plan Sponsor-Responsible Party Signature

Clear
Date

MonthDayYear
Date
Employer Plan Sponsor Email Address:
example@example.com
Employer Plan Sponsor Phone Number
Please enter a valid phone number.
Employee Pay Frequency
Broker/Referral Partner Signing Form – Printed Name
Date

MonthDayYear
Date
Group Health Questionnaire Appendix

Please use this page to provide more detail to responses in the Group Health Questionnaire which requested further explanation.

	Explanation
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13

Should be Empty: