Risk Transfer

Risk Transfer Initial Inquiry Service Employee Benefits Stop Loss

Our risk transfer initial inquiry service is available to service provider members seeking insurance and reinsurance solutions for their clients.

The service is designed to allow you to source potential providers and save time by providing initial information which will allow them to respond to you if they can assist you.

You can select which providers you wish to send the information to once you have completed the information below.

You can choose to provide as little or as much information as you wish but the more detail that you provide will allow a more detailed response.

Once a provider has expressed interest then in most cases you will be required to supply a more detailed application as required by each provider.

Log in to your account

Members

Submit your Inquiry

Client Information

Company Name, Group Name or Your Reference Number

What does the Company or Group do?

About the Cover

Proposed Start Date

What is the required Specific Deductible?

What is the required Aggregate attachment point

Type of Contract Requested

Incurred and Paid
Paid Only
Other (please specify)

Please briefly describe the plan and whether it includes ancillary coverages such as dental, vision, disability and life.

Covered Lives

What is approximately the total number of eligible employees?

What is approximately the total number of retired employees that you wish to be covered?

What is approximately the total number of COBRA employees that you wish to be covered?

Do you wish to include life cover?

What is the total number employees that you wish to cover for life only?

Claims Data

Please supply paid claims data for the two-year period before the proposed start date after any recoveries (if applicable).

Loss Experience (last 2 years)

Year	Number of Covered Lives	Total Paid Medical	Total Paid Medical after stop loss recoveries

Large Losses

Please supply data for all claims which have exceeded or are expected to exceed more than 50% of the proposed specific deductible in last 2 years as follows: Claim 1 Age of Claimant

Status

Diagnosis, Type of Treatment and Prognosis/Expected Outcome and future costs.

Add New Claimant

Funding

Do Employees contribute to the plan? If so please describe the amounts or percentages paid by employees.

Loss Control

Please provide details of any contracted loss prevention or loss control services such as Preferred Provider Organizations, Large Case Management, Wellness or Rehabilitation Programs that your client uses..

By ticking the box I confirm that I have read and agree with selfinsurancemarket.com's terms and conditions. Click here to view the terms and conditions.