Great-West Healthcare

Great-West Healthcare

New Case Setup Questions & Checklist

If filling form out electronically, use “TAB” to move from one field to the next. Please do NOT hit “ENTER.”

1.Full legal name of company:

Street Address:

City:State:Zip:

  1. Shipping address (if different from above):

Street Address:

City:State:Zip:

  1. Tax ID # of the company:
  2. Company type (C-Corp, S-Corp, LLC, etc.):
  3. ERISA Compliant: Yes No
  4. Is this plan administered according to Section125 regulations of the Internal Revenue Code: Yes No
  5. Fiscal year of company (ex. Jan- Dec):
  6. Any subsidiaries? YesNo If yes, list with % ownership:
  7. Grandfathered status: YesNo
  8. Plan administrator name and contact info:

Name:

Official Title:Phone:( )Fax:(

Last 4 digits of SSN: E-mail address:

Legal/formal contact: Yes No

If no, who is the legal/formal contact? Phone:( )

Last 4 digits of SSN: E-mail address:

Official Title:

Is COBRA contact same as plan administrator? Yes No

If no:Last 4 digits of SSN:E-mail address:

11.Any additional Client Portal Resources (administrative website) users’ contact info?
(Same information needed as noted in previous question)

Name:

Official Title:Phone:( ) Fax:( )

Last 4 digits of SSN: E-mail address:

12.Are retirees covered? Yes No

13.What is the employer contribution strategy for medical insurance?

Different contribution strategy for potential different classes of employees?

EE% DEP%

New Case Setup Questions & Checklist (continued)

14.Reinstatement Rules: Standard 3 months; Non-Standard: Days Months; No Reinstatement

15.Max dependent child age?26Max full-time student age:26

Is eligibility dependent on full time student status?Yes No(if “no,” additional rate increase may apply)

16.How many hours/week to be eligible for benefits?

17.Are any classes of employees excluded from eligibility? Yes No

If yes, which classes of employees?

18.Are domestic partners to be eligible for coverage? YesNo(if “yes,” additional rate increase will apply)

Same and/or opposite sex? Same Opposite sex

19.How long do new hires have to wait before becoming eligible?

20. Termination Date: Last Day of Month Date of termination

21.Does the Waiting Period apply to initial enrollment? Yes No

22. Waive pre-existing conditions during initial enrollment? Yes No

23.Are there separate eligibility requirements for potential different classes/divisions of employees?YesNo

If yes, please describe in detail:Hourly has a 90 day waiting period; Salary has no waiting period

24.Is divisional billing required (each division must have at least 25 employees)?YesNo

25.Name of prior carrierYears with prior carrier:

Type of plan(s)Reason leaving carrier(s)

Additional carriers for last 5 years:______

26.Co. name to appear on ID cards (32 character limit including spaces):

27.Banking information (re: Info for account for monthly ACH transfer):

Bank name: N/A

Address:

Account #:ACH transit #:

Bank contact name:Phone number(317 )

Exact name of bank account:

Confirmation if account is checking or savings:CheckingSavings

Please note following checklist of items needed in order to submit new group:

Voided check (for account to be used for monthly funds transfers) or Micro-encoding sheet from bank*

Deposit check amount ($ )

Copy of prior carrier list bill (most recent bill)

Copy of prior carrier renewal rates

DES/SES Spreadsheet or Employee enrollment applications (SS#, DOB, DOH, signature, date, etc.)

Tax and wage statement listing all employees (most recent quarter) aka “UITR”

Completed/signed signature pages (returned along with items listed above)

* Needed only for FBA setup if elected or if account to be tapped is not a checking account or if account is new.

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