A complete and current census including the following information:
Gender
Date of Birth
Does your plan cover retirees?
Level of coverage (Emp Only, Emp+Sp, Emp+Ch, Family)
Zip Code
Additional Data Needed if already Self-Funded or Level-Funded:
Current & Renewal Rates (specific and aggregate) and funding factor
3-year History
3-Years of Aggregate/Specific Reports
Schedule of Medical Benefits
Schedule of Prescription Drug Benefits
All claimants who have reached $10,000 or are expected to
Anyone on a Transplant waiting list
Any members who are disabled (including spouses)
Additional Data Needed if already Fully Insured:
Current & Renewal Rates
Schedule of Benefits for Medical/Prescriptions
Any known high claimants
Statement of Health
For a copy of the Health Statement, please contact Jessica Groves at jessica@dbainc.org
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