Application For Stop Loss Insurance - Hm Insurance Group
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2P.O. Box 535061, Suite P6518
Pittsburgh, PA 15222-3099
APPLICATION FOR STOP LOSS INSURANCE
Please Type or Print – Must be completed in full.
APPLICANT INFORMATION
Full Legal Name of Group (to appear on Policy)
Key Contact Person
Tax ID Number
Business Telephone Number
Fax Number
E-mail
Internet
Address
City
State
Zip Code + 4
Delivery Address (if different than above)
City
State
Zip Code + 4
Nature of Business
SIC Code
Corporation
Partnership
Government
Other*: _____________________
*If an Association, Trust or Charitable Organization, a copy of the bylaws and/or trust is required with the submission of the application.
If a union, or if union employees are covered, a copy of the collective bargaining agreement is required with the submission of the
application.
Affiliates to be insured?
Yes*
No
*If “yes,” complete the table below, attaching additional sheets if necessary.
Full Legal Name
Nature of Business
AFFILIATE #1
Address
City
State
Zip Code
Full Legal Name
Nature of Business
AFFILIATE #2
Address
City
State
Zip Code
Full Legal Name
Nature of Business
AFFILIATE #3
Address
City
State
Zip Code
THIRD PARTY ADMINISTRATOR (TPA)
Full Legal Name of TPA
Tax ID Number
Business Telephone Number
Fax Number
Address
City
State
Zip Code + 4
Delivery Address (if different than above)
City
State
Zip Code + 4
Key Contact Person
E-Mail
Internet
PRODUCER (Agent/Broker)
Name
License Number(s) – Please attach a copy, if not on file.
Tax ID Number
Business Telephone
Fax Number
E-mail
Internet
Number
Address
City
State
Zip Code + 4
Requested Effective Date
Single:
Family:
Total:
Estimated Initial Enrollment:
_____________________
_____________________
______________________
st
Premium Deposit of $ _______________ included. Estimated 1
month’s premium must be attached to this application. The
Premium Deposit will be applied to the first premium when due. Make check payable to Highmark Casualty Insurance Company. Do
not make the check payable to the agent or leave the “Payee” blank. If a policy is not issued, the premium deposit will be refunded in
full.
HC-SLA WD
Page 1 of 2
Applicant’s Initials: _____________
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