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REQUEST FOR KEREON CDHP PROPOSAL
All information is necessary to calculate the Analyzer. Information with an Asterisk * is required to submit form. Once this form is received, a Kereon representative will contact you.

Please include rates and summary plan descriptions for all current and proposed plans.

 

Today's Date
 

Plan Delivered Date
 

Your E-Mail* 

Plan Renew Date
 
Company Information

Company Name (specify if dba)
C Corp Sub S Partner
Company Type

Address/City/State/Zip

Web Site

CEO's Name 

CEO's E-Mail

CEO's Phone/Ext

CFO's Name

CFO's E-Mail

CFO's Phone/Ext

Key Contact Name

Key Contact E-Mail

Key Contact Phone/Ext

Key Contact Position

Key Contact Location
 
Consultant/Agent

Company Name

Address/City/State/Zip

Web Site

Consultant/Agent Name

C/A E-Mail

C/A Phone/Ext

Key Contact Name

Key Contact E-Mail

Key Contact Phone/Ext

Key Contact Position

Key Contact Location
Are you currently Agent of Record with this Company?     Yes    No
 
Eligibility/Census
     
 
Current
Proposed
Total Number of EE
FT
PT
FT
PT
Total Electing Coverage
Total Electing EE Only
Total Electing EE+Dep
Total Electing EE+Spouse
Total Electing EE+Family
 
Migration and Trend

Will this Plan be a Universal Install (Entire Group), or an Option with Other Plans?
Yes - Universal Install with 100% migration
Quoted as an option, but will not replace any current plans
Quoted as an option, and will replace plan (plan name)

Expected Migration to CDHP Plan (complete for option plans only)
Unknown - please quote low and high expected migration examples/or
Please quote annual expected migration (percentage of EE remaining in current plan versus moving to a CDHP) as:

% Year 1     % Year 2     % Year 3     % Year 4     % Year 5
 
Summary of Benefits
     
 
Current
Proposed
Renewal
Calendar Plan
Calendar Plan
Health Plan Name & Number
Deductible: EE
Single    Family
Single    Family
Coinsurance: EE
Single    Family
Single    Family
Co-pay Per
OV   ER   Rx
OV   ER   Rx
Coverage Type
Self Funded   Fully Insured
Self Funded   Fully Insured
Additional Plans - Please attach if possible
FSA  HSA  HRA
Other
FSA  HSA  HRA
HRA/HSA
Premium or Premium Equivalency or COBRA (% or $ amount)
ER Health Plan Monthly Contribution
EE
EE+Sp
EE+Dep
EE+Fam
EE
EE+Sp
EE+Dep
EE+Fam
EE Health Plan Monthly Contribution
EE
EE+Sp
EE+Dep
EE+Fam
EE
EE+Sp
EE+Dep
EE+Fam
COBRA Rates
EE
EE+Sp
EE+Dep
EE+Fam
EE
EE+Sp
EE+Dep
EE+Fam
ER Sec. 125 Matching Contribution
(Ex:ER matches $1 for EE $2 = 33%)
Single %   Family %
Single %   Family %

Proposal Type Requested - Request Kereon's recommendation, or choose a plan:

Request Kereon Recommended Custom Blended CDHP

CDHP HSA
CDHP HRA
CDHP HRA/HSA Blend
$ Annual Fixed HSA or
$ Annual Variable HRA
ER HRA Contribution
EE
EE+Sp
EE+Dep
EE+Fam
EE
EE+Sp
EE+Dep
EE+Fam
ER HSA Contribution
Matching
Fixed
Single
Family
Matching
Fixed
Single
Family
Max Out Of Pocket (MOOP) In Network
Single    Family
Single    Family
Is Deductible included in MOOP?
Yes  No
Yes  No
Is there any additional information you would like us to know?
   
 
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1161 Wayzata Blvd, #184
Wayzata, MN  55391
Phone: 952.449.3618
Fax: 952.449.3619