Simply contact one of our sales and marketing staff:
405.848.1975
800.825.3540
sales@maa-tpa.com

Information Needed For Risk Evaluation

1. Group Information
   1. Complete name of the group
   2. City, State, Zip Code (if subsidiary locations, provide zip (1st 3 digits) and # or % of employees for each location)
   3. SIC Code or nature of business
   4. Are there any HMO’s? How many employees insured with the HMO? Will HMO be eliminated?
2. Census
   1. Date of birth (or age)
   2. Sex
   3. Single or family coverage
   4. Life insurance Volume, if applicable
   5. Locations (city, state, zip code of each location if applicable)
   6. Indicate retiree coverage
   7. COBRA participants, along with expected date of COBRA termination.
3. Schedule of Benefits
   1. Complete copy of your present benefit booklet
   2. PPO information
4. Claims Experience

   If fully insured or minimum premium:

   1. Premium, rates, and cumulative claims information

   If self-funded:

   1. Month by month claims experience for the current year;
   2. Month by month claims experience for the previous two plan years;
   3. Month by month enrollment for each experience period.
   4. Stop Loss contract type (12/12, 12/15, Paid, etc.).
5. Shock Loss Information
   1. Please list all participants who have had claims paid on their behalf in excess of 50% of the specific deductible, or claims in excess of $10,000 during the current or past two plan years.
   2. Please include diagnosis, prognosis, and present status (including expected treatment) of the participant.
6. Current Rates