Obama signs stopgap COBRA subsidy extension
Date: 03/05/2010
WASHINGTON—President Obama signs into law legislation that provides a stopgap, 31-day extension of federal subsidies of COBRA health care premiums.
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Obama signs stopgap COBRA subsidy extension
Date: 03/05/2010
WASHINGTON—President Obama signs into law legislation that provides a stopgap, 31-day extension of federal subsidies of COBRA health care premiums.
Read More
COMPANY INFORMATION
Company Name:
Address:
City: State:
Zip code: Renewal Date:
Open the calendar popup.
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:
  $
  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?
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?
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?
4. Are any employees or dependents currently pregnant?
If yes – please indicate how many:
Due dates:
Has any insured received medical benefits in excess of $25,000 in the last 12 months?
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.

 

 
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