Note to group:  You must COMPLETELY fill out this checklist and submit the checklist to Underwriting prior to receiving medically underwritten  rates.with the complete sales package.  The information provided on this checklist will be used by Underwriting to determine whether the applicant meets BCBSRI minimum underwriting policies at all, the scope of coverage to be offered, and whether the applicant is to be classified and/or rated as a small or large employer.  Rhode Island law now prohibits us (or any small employer carrier) from issuing coverage to any group with fewer than 51 eligible employees enrolled, without first receiving the information, documentation, and waivers described in this form.To help expedite the renewal process and ensure continued coverage, please complete this form in its entirety and return it with all required attachments in the postage-paid envelope provided. This form and any additional materials submitted are considered confidential and proprietary and are only used in the Underwriting Department for recertification purposes.                                                                  





  Section I – General Information





   Name of Employer:  ___________________________________ Effective Date of Coverage: ________________________________________





   Street Address of Primary Business Location: ________________________________________________





   City: ____________________________      State: __________________     Zip Code:  _________________





      Telephone : ______________  Extension: _______  Fax: _______________  E-mail: ____________


   Telephone: ________________ Extension: _______ Fax: ________________ E-mail: _________________Name of Plan Administrator:__________________________________________________________



   Name of Plan Administrator: _______________________________________________________________



   Was the employer formed for the purpose of buying health insurance?   Yes ____  No ____    


   Current Carrier _______________________



   Was the employer formed for the purpose of buying health insurance?   Yes ____  No ____

    BCBSRI Group Number (found on your monthly bill): __________  Renewal Date: _____________




Monthly Rates



   Current Carrier ________________________    Are the following rates Renewal or Present Rates? ______

Benefit PlanIndividual Rate _______________________________


Sub/Spouse EE/Spouse

Rate _________ Employee/Children Rate ___________ Family Rate _______________EE/Child(ren)


















   If your Workers’ Compensation carrier is Beacon Mutual, PLEASE ENTER POLICY NUMBER:_____________If your Workers Compensation carrier is Beacon Mutual, please enter your policy number:________











  Section II – Employer Information (If more space is needed, please attach a separate sheet.)





   A.   Does this business have offices/locations at other addresses or in states different fromother than your primary
your primary location listed above?  Yes____ No____  If yes, please provide the
information below:


City/State                                                                   Number of eligible employees





   B.      DoesDoes t this group own any other business, ; is this group jointly or cooperatively managed or

          operated with

         another business, ; or do the owner(s) of  does this group also hasve full/partial

          ownership of any other  business??


        Yes ____ No ____




          If yes, please provide the following:



          Name of Business             Names of Owners                            Percentage of Ownership (for each owner)


        _____________________  ____________________________  _______________________________


        _____________________  ____________________________  _______________________________


        _____________________  ____________________________  _______________________________




        _____________________  ____________________________  _______________________________







  Section III – Rate for the following products:


  Riders:                                                                                   Drug Options:


    ¨    Acupuncture                                                                                                                     ¨         $      5/15/30/30

    ¨    Vision                                                                                                                                        ¨                                                                                                      $710/2535/4060/40100

                                                                                                                                    ¨         $7/30/50/75

                                                                                                         ¨            $7/30/50/75 $500 Deductible



¨      Essential Dental                                                                                                                                                                                                                                                                                        


Before mailing this form, please ensure that you have included the required
documentation that is requested in Section III of this package.






  Section III –Status of Employees Eligible for Health Insurance      




   Your certification cannot be completed if you do not submit the following supporting
documentation with th
e renewal certification form.  If you have any questions on the
required documentation, one of our Recertification Specialists would be happy to
assist you.  Please call (401) 459-5528 between 8:15 a.m. and 4:30 p.m. Monday through
Friday.  Please see enclosed Bulletin 2002-5 from the Rhode Island Department of Business
that further explains the necessity of this information.





  Section IV – Status of Employees Eligible for Health Insurance


    Your group coverage cannot be implemented if you do not submit the following supporting
    documentation with this form.



A. Supporting documentation*


A. Supporting documentation*


     You must document that every individual meets the requirements of an "eligible
employee,” including owners of the group.  (The definition of an eligible employee can be found in Appendix One.) In general, payroll will provide that ithis information
because it will show that an individual is an employee who works the minimum number of hours per month.


All wage information may be blacked out for confidentiality purposes.




  *Acceptable forms of supporting documentation are listed below in order of preference:


            1.  Most recent Schedule C, Schedule K1, or 1120S Schedule K for all owners of each business;


            2.  Most recent payroll report from a third party payroll processing company

                  (for example, ADP or Paychex);


            3.  Most recent Quarterly Tax and Wage Report;


            4.  1099s for any employee who fits the definition of an eligible employee, but

                  does not appear on any document listed above;


            5.  In addition, you also need to supply a W-4 form for any new hire not appearing

                  on the tax documentation (You must indicate their hire date on the form.).





Please note: Any payroll documentation submitted should have contain the eligibility status for each employee as follows:
coded with their


eligibility status.  The coding should be as follows:



            E - Enrolled 


            W – Waiver


            PT - Part time


            S – Seasonal


            T – Terminated


            Temp – Temporary


            P - Fulfilling probationary period, please note date of hire and group’s probationary period


            COBRA - For groups with 20 or more employees, please provide last payroll the employee

                             appeared on note start date of COBRA




B. Waivers




      Please provide a waiver form for any eligible employee or their his or her eligible dependent
who is not currently enrolled on the group plan (copy of waiver form attached).



















  Appendix One –  Definitions




   1. Eligible Employee




      "Eligible employee" generally means an employee who works on a full-time basis
with a normal work week of thirty (30) or more hours.  At your sole discretion,
"eligible employee" can include all full-time employees who work a normal work week
anywhere between seventeen and one-half (17.5) and thirty (30) hours, as long as you
apply the same eligibility criteria to all employees and without regard to any health
status related factor.




      The term "eligible employee" may include a self-employed individual, a sole proprietor,
a partner in a partnership, and an independent contractor if any of those individuals
are included as employees under your health benefit plan.




      The term "eligible employee" does not include temporary employees, substitute
employees, or employees who work less than seventeen and one-half (17.5) hours
per week.  Any retiree under contract with any independently incorporated fire district

       is also included in the definition of eligible employee.




   2. Small Employer




      "Small employer" means any person, firm, corporation, partnership, association,
political subdivision, or self-employed individual that is actively engaged in business,
including, but not limited to, a business or a corporation organized under the Rhode
Island Non-Profit Corporation Act, Chapter 6 of Title 7, or a similar act of another state
that, on at least fifty percent (50%) of its working days during the preceding calendar
quarter, employed no more than fifty (50) eligible employees, with a normal work week
of thirty (30) or more hours, the majority of whom were employed within this state, and
is not formed primarily for purposes of buying health insurance and in which a bona fide
employee-employer relationship exists.  In determining the number of eligible employees,
companies that are affiliated companies, or that are eligible to file a combined tax return
for purposes of taxation by this state, shall be considered one employer.