MASTER APPLICATION FOR SMALL GROUP EMPLOYERS

COMPANY INFORMATION
Exact Legal Name of Company:
"Doing Business As" (DBA):
Street Address
City
State
Zip Code
Billing Address (if different from above):
City
State
Zip Code
Tax ID:
SIC Code:
Type of Business:
Years in Business:
Key Contacts
HR Manager is also Billing Contact
HR Manager: Phone: E-mail:
Billing Contact: Phone: E-mail:
MediExcel Health Plan is an environmentally conscious organization that takes great pride in reducing paper waste. By signing our Master Application, you acknowledge that all Plan documents, including invoices will be sent to you via e-mail.
CA Coverage Health Insurance Carrier(s):
Name of Current Workers’ Comp Carrier:
Those not covered by Workers’ Comp (List names and why):
Premium Billing Reference:
Bill One Location Bill Multiple Locations
Other Health Insurance Plans Offered:
Requested Effective Date:
Rate Structure:
3-Tier 4-Tier
PLAN SELECTION
MediExcel Health Plan Offering:
P5 Platinum HMO Plan
P20 Platinum HMO Plan
PM Platinum HMO Plan
GM Gold HMO Plan
*MINIMUM OF 3 ENROLLED EMPLOYEES REQUIRED FOR PM, P5 AND P20 PLANS
Enrolling in MediExcel Dental Plan:
Yes No
If Yes, choose Dental Plan option:
D100 D200
Choose tier level::
3-Tier 4-Tier
*CAN BE OFFERED AS VOLUNTARY
Enrolling in MediExcel Vision Plan:
Yes No
If Yes, confirm Vision Plan option:
V100
Choose tier level::
3-Tier 4-Tier
*CAN BE OFFERED AS VOLUNTARY
**ACTIVE MEDIEXCEL MEDICAL COVERAGE REQUIRED
OWNER/CORPORATE INFORMATION
Company is a: Sole Proprietor Partnership or LLC Corporation Non-Profit
REQUIRED ENROLLMENT INFORMATION
Total # of
Employees:
Total # of Benefit
Eligible Employees:
Total # Enrolling in
Mediexcel Health Plan:
Total # Enrolling in other
Employeer Sponsored Plans:
Total # Declining
Coverage:
 
Is your group currently subject to Federal COBRA? Yes No
(Employed 20 or more total employees during at least 50% of the working days in the previous calendar year)
Number of existing COBRA or Cal-COBRA participants:
Name of your COBRA or Cal-COBRA Administrator:
Number of hours required per week to be eligible for benefits:
Full-time EE's: 30 hours 40 hours
Other
Do you want to cover part-time employes that work 20-29 hours?
Yes No Other
Employer Contribution Levels:
Employee % or $

Dependent % or $
Waiting Period for New Hires and Rehires
1 st of the month following days (for new hires).            1 st of the month following days for (rehires).
EMPLOYER HEALTH QUESTIONNAIRE (Complete ONLY if 10 EE’s or less are enrolling)
Please answer the following questions to the best of your knowledge for your employees and/or dependents enrolling in MediExcel Health Plan, including any COBRA participants.
1) Is there any enrolling employee who will be covered under this plan who has received an excess of $20,000 in
medical care expenses in the last 2 years?  Yes  No
2) Is there any enrolling employee to be covered under this plan who is unable to work or attend school due to an injury or illness?  Yes  No
FOR EACH QUESTION ANSWERED “YES,” PLEASE EXPLAIN TO THE BEST OF YOUR ABILITY:
QUESTION #____: _______________________________________________________________________________
QUESTION #____: _______________________________________________________________________________
RESPONSIBILITIES FOR DISTRIBUTION OF THE SUMMARY OF BENEFITS AND COVERAGE (“SBC”) TO PARTICIPANTS,
BENEFICIARIES OR ELIGIBLE EMPLOYEES:
MediExcel Health Plan:
Upon application: as part of any written application materials provided by MediExcel Health Plan
Upon request
Employer Group:
All other SBC delivery requirements including, but not limited to, delivery to special enrollees, delivery to enrollees added to the Plan after open enrollment and newly eligible employees
Application is hereby made for a MediExcel Health Plan Group Subscriber Agreement. This is an application only. Issuance of a Group Subscriber Agreement is subject to receipt of first month's premium and review and approval by MediExcel Health Plan. All eligible employees and dependents will be offered this benefit package. If accepted, the employer agrees to make required payroll deductions based upon the contributions established herein for all employees who enroll in this plan. The applicant also agrees to notify all eligible employees of their ability to enroll in the plan after their waiting period.



Printed Name and Title

Date
REQUIRED BROKER / GENERAL AGENCY INFORMATION (PLEASE COMPLETE ONE OPTION)
Broker Agency: Broker Name:
Broker/Agent Signature: Date:
Tax ID: License #: Telephone #:
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