GROUP PRESCREEN                       Insurers Administrative Corporation
                                                                                               IAC Reference Number:        ___________________

TO:       IAC Pre-Screen Coordinator                                         Fax Back to:

E-mail: PrescreenG@iacusa.com or  Fax:(928) 395-3770        General Agent Name: __________________________

Phone: (800) 276-2707 ext. 8335                                                General Agent Fax No.: ________________________

General Agent:  Complete this Pre-Screen Worksheet and fax/email it to the IAC Pre-Screen Coordinator at the number shown above.  IAC will then review the information supplied and will fax back our proposed underwriting action.

Insurers Administrative Corporation

Group Underwriting Pre-Screen Worksheet

General Agent Information

General Agent Name:

General Agent #:

General Agent Phone No.:

General Agent Fax No.:

Today’s Date:
       

Group Information

Group Name:

State and City of Company:

Nature of Business:

Multiple Locations:      € Yes      € No

List multiple locations and number of employees at each site:
     

Plan Information

IAC Plan Name (i.e., PPO 80/60):

Deductible:

IAC Prescription Plan:

Current Health Carrier:                                                                                                  Total Premium:

Total Number of Employees in Group:

Total Number of Spouses Applying for Coverage:

Total Number of Employees Applying for Coverage:

Total Number of Children Applying for Coverage:

Total Number of COBRA Participants:

 
       

Health Conditions

Employee, Spouse, or Child Name

Age/Sex

Diagnosis/Medical Condition

Date of Onset

Describe Treatment and List Medications Being Taken

Recovery Date or Ongoing Condition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IAC’s Proposed Underwriting Action

Best Case:        Medical/Prescription Load:                                 Industry Load:   

 

Underwriter:

Date:

Disclaimer:  This is an estimate based on the information supplied.  This pre-screen is not a guarantee of coverage and is not intended to replace the medical underwriting process.  A change in any information provided, including but not limited to, number of employees, age and gender of employees, or medical or health history, may cause this estimate to change or become invalid. This transmission contains information from Insurers Administrative Corporation that may be confidential and protected under state and federal law, including the HIPAA Privacy Rules.  Such information is intended solely for the named recipient.  Use by any other party is not authorized.  If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of this transmission, its contents, enclosures or attachments is expressly prohibited.  If you have received this transmission in error, please notify us immediately by telephone at (800) 276-2707  Thank you.

Please include a copy of this pre-screen with the case submission. 

PS WS (09/03)