LifeWise Administrators New Group Set-Up

Instructions: Please provide all information below. Do not provide this document with missing information. Once complete, email this document to BOTHLifeWise Administrators (internal mailbox) ANDContract Services (internal mailbox).

Information Required from current TPA or Group (Spreadsheet available):

Enrolled / Notified
  • Name (including Dependents)
/
  • Name

  • Qualifying Event
/
  • Qualifying Event

  • Qualifying Event Date
/
  • Qualifying Event Date

  • SSN
/
  • SSN

  • Address
/
  • Address

  • Date of Termination
/
  • Date of Termination

  • COBRA Start Date
/
  • Date of original COBRA Notice

  • Current COBRA Coverages
/
  • Active coverages at time of termination

  • COBRA Paid Through Date

To be filled out by sales/sales support:

Group Information
Group Name: / Tax ID:
Address: / Size of Group:
City: / Contract Effective Date:
State & Zip Code:
# of Carriers:
Has there been a carrier change for this plan year? / Yes No
Who will notify participants of open enrollment? / LifeWise Group
Is the Group purchasing Retirement administration? / Yes No
Business & Contact Information
Type of Business:
Contact 1: / Telephone:
Contact 2: / Telephone:
Producer: / Telephone:
Sales Rep: / Telephone:
Medical Carrier Information
Carrier Name: / Group Number:
Phone #: / Email:
Renewal Date: / Plan Name:
Address:
Is this a minimum premium or self-insured group? / Yes / No
Is a Conversion Privilege offered? / Yes / No
Dependent Coverage: / Children to Age / Student to Age
Benefits Term after Termination: / End of Month Date of Termination Other:
Is there any need for specialty reporting? / Yes No
Comments:
Dental Carrier Information
Carrier Name: / Group Number:
Phone #: / Email:
Renewal Date: / Plan Name:
Address:
Is this a minimum premium or self-insured group? / Yes / No
Is Dental coverage offered on a stand-alone basis? / Yes / No
Is a Conversion Privilege offered? / Yes / No
Dependent Coverage: / Children to Age / Student to Age
Benefits Term after Termination: / End of Month Date of Termination Other:
Is there any need for specialty reporting? / Yes No
Comments:
Vision Carrier Information
Carrier Name: / Group Number:
Phone #: / Email:
Renewal Date: / Plan Name:
Address:
Is this a minimum premium or self-insured group? / Yes / No
Is a Conversion Privilege offered? / Yes / No
Dependent Coverage: / Children to Age / Student to Age
Benefits Term after Termination: / End of Month Date of Termination Other:
Is there any need for specialty reporting? / Yes No
Comments:
Other Carrier Information (i.e. EAP)
Carrier Name: / Group Number:
Phone #: / Email:
Renewal Date: / Plan Name:
Address:
Is this a minimum premium or self-insured group? / Yes / No
Is a Conversion Privilege offered? / Yes / No
Dependent Coverage: / Children to Age / Student to Age
Benefits Term after Termination: / End of Month Date of Termination Other:
Is there any need for specialty reporting? / Yes No
Comments:
COBRA Premium Rates
Please do not include the 2% administration fee in the rates.
Medical / Vision / Dental / EAP / Other:
Employee only:
Employee/Spouse
Family:
Employee/Child(ren):
Spouse:
Spouse/Child(ren):
Child(ren):
Over Age Dependent
Additional Rate Questions
Is there an additional charge for 2 or more children? /

Yes No

If so, please specify.
Are any benefits offered on a stand-alone basis? /

Yes No

If so, please specify.
Is the Vision plan included with the Medical or Dental plan? /

Yes No

If so, please specify which plan.
If not, is the vision plan offered on a stand-alone basis? /

Yes No

Comments:
Previous Insurance Carrier Information (If Applicable)
Carrier: / Group Number
Names:
Address:
Rates:
Plan Descriptions:

COBRA ADMINISTRATION OPTIONS – ChOOSE ONE OPTION (1-3)

Pricing Structure
1. / Per Employee Per Month (PEPM). This is a flat fee per employee.
2. / Standard Pricing Structure
SERVICE / PRICE
Initial Setup / $
Billing and Premium Collection / $ per billing per month
Reporting or invoicing to more than one plan sponsor location / Number of locations / $ for each additional location per month
Applications, billing or invoicing for more than one carrier / Number of carriers / $ for each additional carrier per month
Standard Notices
End of eligibility notice, termination notice, second qualifying event ineligibility notice / $ per notice
COBRA Election Notices / Yes / No / $ per notice
Open Enrollment Notice & Info / Yes / No / $ per packet
Other Notices (describe):
$ per notice
3. / Other:

In addition to the fees shown above, LifeWise Administrator shall retain as an administration fee an amount equal to 2% of the applicable premium collected for each COBRA member.

LifeWise Administrators 024937 (03-2012)