Location of branch offices and phone numbers: Location Phone

Is your firm owned by, or affiliated with any organization(s) directly, or indirectly, in any area or aspect of insurance or reinsurance? Yes  No If yes, please indicate name, relationship and nature of business.

How long has your organization been operating as a claims payer?

Persons to contact for:   Phone & Extension Company Relations: Premium Accounting: Claims Administration:

List top 2 executives: (please provide a resumé, if applicable) Name Title Length of Service

How many trained claims examiners, including the supervisors, are employed? Number of support staff?

Are all claims examiners, supervisors, draft typists and claims clerks bonded? Yes  No If yes, state limits. Insurer Policy Number Term

What is the claims processing procedure that you use? Manual Automated System computes the claim System accepts manually computed data If claims processing is automated, briefly describe the hardware and software used. Was the program purchased by your company, or was it internally developed?

Are records maintained which would allow retrieval of the following information? (please provide sample reports if available)   A.  Date medical expense was incurred by claimant Yes No B.  Date medical expense was paid by the group Yes No C.  Enrollment, eligibility employment dates Yes No D.  Liability determination (i.e. COB, Workers Comp, etc) Yes No

Do you have a system for Medical Case Management? If so, what factors lead a case into management? (i.e. Diagnosis, Dollar Amount Paid, Prognosis, etc) Yes  No If so, what factors lead a case into management? (i.e. Diagnosis, Dollar Amount Paid, Prognosis, etc)

Are you in a state that requires Third Party Administrators to be licensed? If so, please provide a copy of license. Please also provide a copy of your current state Accident and Health License(s) for either your firm, or any individuals if the state requires them. Yes  No If applicable, please state which licenses.

Approximate number of Stop Loss quotes you expect during the next 12 months? What percentage do you expect to close?

Employer sponsored benefit plans currently utilizing your firm to administer the claims and other administrative functions.

List details of cases you are presently administering:     Number of cases Number of covered employees Fully Insured: Minimum Premium: Self Funded: MEWA, Assoc, Union:

List excess insurers (stop-loss carriers) who have granted your firm authorization to administer claims for their self funded groups. Insurer % of In Force stop loss policies Contact Person

Do you have a profit sharing/commission or similar arrangement with any of these carriers? Yes  No If so, please provide details.

Do you have underwriting or binding authority for any of the insurers listed above? Yes  No If so, for whom?

Do you carry fiduciary and / or E & O insurance? Yes  No If so, please provide the name of the carrier, policy number, limits of liability and terms.

Has any insurance company ever withdrawn their underwriting, binding or claims paying authority? Third party claims administration approval? Yes  No If so, please detail.

Have any legal actions been brought against your firm or any of the principals? Yes  No If so, provide details. Are there or have there been any lawsuits or insurance department complaints against your firm? Yes  No If so, provide details.

What type of "fee structure" (flat, per claim charge, cost plus, percentage of claims, etc.) is utilized by your firm?

Will your firm provide a current financial statement? Yes  No

Your firm's gross annual income profile.   Insurance commissions % Administration %

Your firm's business development plan.   % Through brokers % Through consultants % Through direct contacts (in-house marketing)

Are there any substantial changes being considered for your organization in the near future?

State any expectations or comments you may have regarding KBM Management and your firm's opportunity to develop a sound business relationship.

COMPLETED BY:

I hereby certify that to the best of my knowledge and belief the above information is correct. I also understand that a routine inquiry of any or all of the individuals and firms hereon noted, as references in this questionnaire, may be made by the company. Contact Person: Title: Date Completed: