Small Business Health Care Tax Credit
Date: 05/07/2010
The new healthcare reform law gives a tax credit to certain small employers that provide healthcare coverage to their employees, effective with tax years beginning 2010.
Read More
The “Plain English” Summary to Healthcare Reform
Date: 05/07/2010
Although the rules for how the new health care reform law will be implemented are still being written, this simple guide makes it easy to understand the changes that are included in The Patient Protection and Affordable Care Act (PPACA).
Read More
The Top Ten Immediate Benefits Americans Will Receive When Health Care Reform Passes
Date: 03/17/2010
Today, the Democratic Caucus of the House listed the provisions of the health reform bill that will take effect “as soon as health care passes,” The legislation would:
Read More
COMPANY INFORMATION
Company Name:
Address:
City:
State:
Select...
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip code:
Renewal Date:
July 2010
S
M
T
W
T
F
S
27
27
28
29
30
1
2
3
28
4
5
6
7
8
9
10
29
11
12
13
14
15
16
17
30
18
19
20
21
22
23
24
31
25
26
27
28
29
30
31
32
1
2
3
4
5
6
7
Nature Of Business:
SIC Code:
Yrs. In Business:
No. of Eligible EE's:
No. of COBRA:
Employer Contribution (MEDICAL):
% or $ for Employee (specify):
% or $ for Dependent (specify):
Employer Contribution (DENTAL):
% or $ for Employee (specify)
% or $ for Dependent (specify)
Current Carrier:
No. of years:
Prior Carrier:
No. of years:
Reason for Quote:
Workers' Comp Carrier:
ANCILLARIES REQUESTED
Dental
Life
$
Vision
Other:
CURRENT COVERAGE (MEDICAL)
MEDICAL Benefits
Plan 1 Name:
HMO
Plan 2 Name:
PPO
Plan 3 Name:
Other
Deductible
Deductible
Deductible
OV Copay
OV Copay
OV Copay
Hospitalization
Co-insurance
Co-insurance
Rx
Rx
Rx
CURRENT COVERAGE (DENTAL)
DENTAL Benefits
Plan 1 Name:
DHMO
Plan 2 Name:
PPO
Deductible
Deductible
OV Copay
Co-insurance
Fee Schedule?
Calendar Year Max
Ortho coverage?
Ortho coverage?
MEDICAL QUESTIONS
Please answer the following questions to the best of your knowledge regarding all eligible enrollees (employee, dependents, COBRA, owners/partners). If any response is “yes,” provide details as indicated below:
1.
Has any employee or dependent been hospitalized in the last 12 months?
Yes
No
2.
Has any employee or dependent had cancer, heart disease or heart disorder, stroke, kidney disorder, diabetes, Acquired Immune Deficiency Syndrome (AIDS), AID-related conditions or any other medical condition during the last 2 years?
Yes
No
3.
Has any employee or dependent been unable to perform his/her usual duties or activities for more than 10 consecutive days during the past 12 months?
Yes
No
4.
Are any employees or dependents currently pregnant?
Yes
No
If yes – please indicate how many:
Due dates:
Has any insured received medical benefits in excess of $25,000 in the last 12 months?
Yes
No
Detailed information for medical questions with a response of “yes”
Condition/Diagnosis:
Date diagnosed:
Medications and Treatments:
Is this condition ongoing?
Physician’s prognosis:
Pending treatments:
Details:
Condition/Diagnosis:
Date diagnosed:
Medications and Treatments:
Is this condition ongoing?
Physician’s prognosis:
Pending treatments:
Details:
Please download and complete the census file and email it to
info@ylinsurance.com
.
Please press the Submit Button ONCE.
Then wait for online confirmation of your request.
Thank you for your interest.
HOME
|
TEAM MEMBERS
|
PRODUCTS
|
LINKS
|
CONTACT US
Designed & Developed By
GET THE EDGE
Copyright 2008 ©
YLIS
. All rights reserved.