Stop loss insurance solutions from IHC Risk Solutions, a member of The IHC Group

Forms

Complete Claims Kit

Questionnaire and Application for Approval

For third party claims administrators

Claim Submission Request Form

Aggregate Claim Form

Aggregate Stop-Loss Report

Large Claim Notification Form

RFP Submission Requirements

The following information should be included in the Request for Proposal (RFP).

Stop-loss insurance quote

  • Name and address of the Group
  • Nature of the business and/or SIC code
  • Effective Date
  • Census, including dates of birth, dependent status, gender, and Retiree and COBRA information
  • Copy or outline of current and proposed schedule of benefits
  • Minimum 2 years of claim experience, if available, and enrollment history on a month-by-month basis
  • 2-year rate history and current Aggregate factors, if applicable
  • Name, period of coverage of current and prior carriers
  • Employer contributions? For employee? For dependents?
  • Minimum 2 years large claims excess of the specific deductible
  • Information on any claim based on Trigger Diagnosis or is expected to exceed 50% of Specific Deductible amount
  • Contract basis (current and proposed) -- i.e., 12/12, 12/15, 15/12, 24/12
  • Current and Requested Specific Deductibles
  • Is there a fully-insured HMO? If yes, how many are participating?
  • PPO - current and proposed
Contact Pat Vignone at 860.289.1844 ext. 301 or Joel McKeever at 856.396.3181 ext. 312 for RFP submission information
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