Stop Loss Coverage Disclosure Statement
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Plan Sponsor: | ||||||
| This stop loss proposal contains a provision regarding
coverage for participants under the group plan that may reasonably be
expected to exceed the selected specific deductible for the proposed
policy period.
Such individuals include those that are currently disabled, not active at work, institutionalized, or diagnosed with a condition deemed to be of a serious nature (such as but not limited to transplant, leukemia, burns, premature birth, HIV, and malignant neoplasm). Additional information is needed on each of these participants as
follows: | ||||||
| EE/Dep | Age | Gender | Claims | Paid/Pended | Diagnosis | Prognosis |
|
The Plan, Claims Administrator, and Producer hereby submit that the above information is complete and accurate, to the best of his/her knowledge and that nothing has been knowingly omitted. Non-notification by the Plan, Claims Administrator, and/or Producer of
any continuing potential large claimant(s) as of the date coverage is
bound will result in the claimant(s) being excluded from stop loss
coverage. | |||
| Plan Sponsor: | __________________________________________________________________ | ||
| Authorized Person | Title | Date | |
| Administrator: | __________________________________________________________________ | ||
| Authorized Person | Title | Date | |
| Producer: | __________________________________________________________________ | ||
| Authorized Person | Title | Date | |