Flex Shield Questionnaire Template
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1
2Flex Shield
Questionnaire
from the Domestic Accident & Health Division of the AIG Companies
®
GROUP PROFILE
Legal Name of Employer _________________________________________________________________________________________________________________________________________________________
Requested Enrollment Period (start) __________________________________________________ (end) _________________________________________________________
Requested Effective Date of Coverage_________________________________________________ IRS Reporting Number _____________________________________
Street Address __________________________________________________________________________ P .O. Box (If Applicable) ______________________________________
City _________________________________________________________________
State _______________ Zip ____________ County __________________________________
Phone Number _____._____.___________ Nature of Business ______________________________________________________ SIC _________________________
Business Type
Corporation
Association
Partnership
Sole Proprietorship
Other _______________________________________________
Other Locations or Affiliated Companies/Subsidiaries to be Included
No
Yes, list name(s) and location(s)
_____________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________
Main Contact _________________________________________________________
Title ___________________________________________
Phone Number ____.____.__________ Fax Number ____.____.__________ E-Mail _______________________________________________________________
ELIGIBILITY
Number of Eligible Employees __________________________________ Number of Enrolled Employees ____________________________________________________
Domestic Partner Coverage
Yes
No
Dependents Coverage
Yes
No
Age Limit:
To age 19, students to age 23
Other _________________________________
TYPE OF FUNDING
True Group (Minimum 50% Employer contribution and 75% employee participation requirement
or 10 lives, whichever is greater)
Non-Contributory (100% Employer Paid and 100% employee participation)
Voluntary Group (Employee Paid and at least 20% participation requirement)
ELIGIBILITY WAITING PERIOD
New Employees
First day of month coinciding with or following ________ days of employment.
Other ___________________________________________
Present Employees
All are eligible immediately, regardless of length of service.
Only those who have satisfied the waiting period are eligible. (Provide hire dates.)
ELIGIBILITY HOURS WORKED PER WEEK
Full time employees working 30 or more hours
Other ___________________________
RATES
EE Only $_________________ EE + 1 (Spouse OR Child) $__________________ EE + Family (Spouse AND Child(ren)) $ __________________
Rate Guarantee
24 months
Other _________________ Commission _________________ %
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Parent category: Life