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Quote Request for Aggregate Stop Loss

RxReins. provides 100% Aggregate Excess of Loss Insurance for Employer paid self-insured freestanding or carve-out Group Prescription Drug Plans for Employees and/or Retirees.

Groups of 50 or more Employees will be considered and there is a minimum annual premium of $1,500 for all Prescription Plans. Coverage is offered for standard 12/12 plans (incurred and paid within 12 months).

The Excess of Loss insurers for these programs are “Best” rated Insurance Companies, and we have underwriting capacity in 50 states.

To obtain a quote for Prescription Drug Excess of Loss Insurance, please provide the following information. You may also download a printable version.

Thank you.

Date Proposal Requested: 12/4/2008

Proposed Effective Date:

Requested by: Agent/Broker    TPA    Other

      Name:
Company:
  Address:
         City: State: Zipcode:
     Phone:() -    Fax:() -    Cell or Pager:() -
      Email:

Employer Information:                                                                               Number of Locations:

Company: Type of Industry:
  Address:
          City: State: Zipcode:
       Total Eligible Employees:            Total Enrolled Employees:
         Employer's Contribution:                % of Employee Cost    % of Dependent Cost

Requested Coverage:

New Benefit Plan Design Co-Pay:                    $Generic     $Brand     Other:
Annual Deductible:      $        Annual Maximum: $      Other:
Will the Plan cover Retiree's? Yes   No
Enrolled Employee Census:                      # of Female Employees:     # of Male Employees:

Employee Age Data # of EE's
w/ Single
Coverage # of EE's
w/ 1 Dep
Coverage # of EE's
w/ Family
Coverage

Under 30

30 - 39

40 - 44

45 - 49

50 - 54

55 - 59

60 - 64

65+

Covered Drugs to INCLUDE:

Yes No

Insulin/Diabetic Supplies

Injectables

Smoking Deterrents

Retin A

Fertility Agents

Anti-Anxiety Agents

Growth Hormones

Anti-Obesity

Vitamins (All)

Pre-Natal Vitamins Only

Sexual Dysfunction

Oral Contraceptives

CURRENT PLAN INFORMATION:

Is there an existing plan? Yes    No
Existing Plan Description:             $ Generic     $ Brand     Other:
Annual Deductible: $ Annual Maximum: $ Other:
Paid Claims:       For the period of:
Paid Claims:       For the period of:

Current Premium Rates: Number of Enrolled EE's

EE Only EE +1 Dep. EE +Fam EE Only EE +1Dep EE +Fam

$ $ $

Does the Plan cover Retiree's? Yes  No Current Plan Renewal Date:

PLAN ADMINISTRATION:

Plan Administrator:
Mailing Address:
         City: State: Zipcode:
Email Address:       Phone:
Is there an Admin Fee? EE Only Per Month $     EE + Family per Month $
Who is the PBM?

EMPLOYEE ELIGIBILITY:

An eligible FULL TIME employee is defined as:
         working hours per week, or Other
An eligible PART TIME employee is defined as:
         working hours per week, or Other
The initial waiting period:
         (a) for current employees on effective date is none , or Other
         (b) for future employees is month(s), or days, or Other
New Hires to be effective on the first of the month following waiting period Yes    No, or
         Other:
Retiree Eligibility: Yes     No
         If Yes, Detail Eligibility:

CONTINUING COVERAGE due to absence from work will be as follows:

For Absence Due To Maximum Continuation Period

     Temporary Layoff Months

     Approved Leave of Absence Months

     Part-Time Employment Months

     Injury or Sickness Months

DEPENDENT ELIGIBILITY - An eligible dependent is defined as an eligible employee's

Spouse Yes No Domestic Partner Yes No

Unmarried children from to age and each unmarried child to age who is a full time student. A full time student is one who is enrolled for semester hours for credit in an accredited junior college or university.