Health Insurance for Small Business
MEDICAL CHARGES NOT COVERED Charges for which benefits are payable in accordance with:
Workmen’s Compensation Law to the extent of such coverage. Intentional self-inflicted injury. Charges incurred because of alcoholism or drug addiction. Injuries sustained while committing a felony.
TERMINATION Coverage for an employee terminates when:
Non-payment of premiums. Termination of your insurance contract with Sagicor. Termination of employment with the employer.
BENEFICIARY Beneficiaries are to be appointed for Group Life coverage. Beneficiaries under the age of 18 years are required to have a Trustee appointed.
CONVERSION Terminating employees have an option to convert to an individual health and/or life insurance policy within 31 days, without medical assesment. BENEFITS
SCHEDULES.
There are 6 benefit plans to choose from:
DOCTOR’S VISITS Benefits Schedules
SURGERY + MATERNITY BENEFITS Benefits Schedules
PREVENTATIVE CARE + OTHER MEDICAL SERVICES Benefits Schedules
MAJOR MEDICAL + DENTAL & OPTICAL + LIFE BENEFITS Benefits Schedules
+
Special Life Insurance
PACKAGE JUST FOR YOU
COMPANY DATA 1. Name of Company Tel
2. Address 3. Principal Officer:
Title:
Email:
4. Plan Administrator
Title:
Email:
5. Type of Business: 6. Nature of Business: 8. Type of Industry:
Sole Proprietorship
Retail Trade
Manufacturing or Wholesaling
Transportation
Partnership
Multi-Industry
Construction or Maintenance
Corporation
Agriculture or Commerce
Other
(a) Number of Full-time Employees/Total Membership (b) No. of Employees with Eligible Dependents
Participation: Dependents Members
n/a
n/a
(c) No. of Employees enrolling (d) No. of Employees with Dependents enrolling
n/a n/a
(e) Will Employees contribute to Employee Coverage?
Yes
No
(f) Will Employees contribute to Dependent Coverage?
Yes
No
Yes
No
10. Company’s Probation Period (Eligibility Period) 11. Name of Subsidiaries and/or Associated Companies:
12. Are the employees of companies given in (9) included in this proposal? 13. Are any classes of employees (other than part-time employees) to be excluded from participation in your plan due to eligibility reasons?
Yes
No
14. Are any of your employees related by blood or marriage?
Yes
No
15. Does this coverage for which you are applying and described herein
Yes
No
replace any other group insurance presently in force? If yes, please answer the following questions and include a copy of your in-force booklet or certificate and final premium billing statement: 1. Name of Insurance Company ................................................................................................................................ 2. Type of Coverage ...................................................................................................................................................... 3. Termination Date ....................................................................................................................................................... 4. Number of Covered Employees as of Termination Date ............................................................................ 5. How long was prior coverage in force? ............................................................................................................
16. Have you, or any of your employees or their dependents incurred any claims in excess of $50,000 during the past 12 months? 17. Have you, or any of your employees or their dependents incurred any claims in excess of $50,000 during the past 12 months? If the answer to any of the above questions was ‘Yes’, explain. (Attach extra sheet if necessary).
EBD-APP02-08-J04/0412
Yes
No
Yes
No