Employer Stop Loss
The following information is requested and can be mailed, faxed, or e-mailed to iiSi
Please contact your designated Marketing Office or Representative
Name, address, location, and industry of group
Effective date requested and due date
Description of current plan and proposed plan, if different
Requested Specific deductible and current Specific deductible
Requested claim basis for Specific and Aggregate
Complete census, indicating any retirees, COBRAs, and HMO participants
Details of any individuals exceeding 50% of the requested Specific during the past 12 months
Details of any disabilities, illnesses or claims expected to exceed 50% of the Specific during the next plan year
Experience: rates, claims and enrollments for the current and prior two policy years
Quote submissions should be sent to email@example.com. If you wish to submit a request for quote via e-mail, please download and use the MS Excel workbook below.
Sheet 1 gives an example of how to enter census data.
Sheet 2 is the actual area where the data is filled in.
The file should be in Excel 4.0 (or higher) format.
Simply fill out the template above and send it to your assigned underwriter at IISI.
Please contact our San Francisco office for the appropriate email address.
Include the completed template as an attachment and send.
If you wish you may also attach your own spreadsheet or database with correct census information and send.