Stop Loss Concepts, Inc. RFP Checklist
Date Proposal Requested: Proposed Effective Date:
Employer Information
Name: Type of Industry:

E-Mail:

Address:

SIC Code: C/S/Z:
Other Locations, Zip, # of Employees:

Requested Coverage
Aggregate Coverage
Attachment Point
125% 120% 115% Other
Self Insurance Maximum
$250,000 $500,000 $1,000,000 Other
Benefits Covered Under Stop Loss
Medical Dental Prescription Drugs Vision Other
Contract Basis Requested
Paid 12/12 15/12 12/15 Other

Other Contract Variations

Specific Coverage

Specific Deductible
$25,000 $30,000 $35,000 $40,000 $50,000 Other
Self Insurance Maximum
$250,000 $500,000 $1,000,000 Other
Benefits Covered Under Stop Loss
Medical Dental Prescription Drugs Vision Other
Contract Basis Requested
Paid 12/12 15/12 12/15 Other
Other Contract Variations

Current Information
Fully Insured Rates: Single 2 Person Family
Self Funded Specific Deductible:
Rates: Single Family Composite
Aggregate Factors: Single Family Composite
Aggregate Attachment Point: Aggregate Rate:

Supporting Information
Employee Census (if census is not on disk, or age banded, it may delay your quote)
3 Years claims history
Large Loss Information (diagnosis, prognosis, course of treatment)
Complete Benefit Summary (including proposed changes)
Complete Provider Network Information Included
Third Party Administrator Information Included
Commission Level