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Information Request: Draft
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For more information about how the Christian Brothers Employee Benefit Trust can serve your organization, please provide the following information. So that we can better serve you, please fill in your contact information completely and accurately. We will never share this information with anyone outside Christian Brothers Services.
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* Contact Name: |
| * Organization: |
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* Number of Employees: |
| * Address: |
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* City: |
| * State: |
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* Zip Code: |
| * Telephone Number: |
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| | Extension: |
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Fax Number: |
| * Email Address: |
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How would you prefer we contact you? |
| * Tax ID Number: |
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You must be an organization in the Official Catholic Directory to be eligible for participation in our programs. Individual coverage is not available.
For more information on inclusion in the OCD, please visit the website: United States Conference of Catholic Bishops |
Listed in Official Catholic Directory? | Page #
| Name of Diocese you are located in? |
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Which benefits interest you? |
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How did you hear about us? |
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Other: |
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If you would like to request a full quote, submit the additional information below: |
Request for Proposal Instructions:
To avoid delays, please make sure you:
- Answer all questions in the top and bottom sections completely and accurately.
- Have the request signed by an individual authorized by the organization to act on its behalf.
- Do not cancel your existing coverage until the proposal process is complete.
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Nature of Business: |
| # of Years Organization in Business: |
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Proposed Effective Date: |
| Does your deductible reset: |
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| | | In Month:
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Have you, in the last 2 years, ever had less than 20 employees? |
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Medicare Secondary Payer Questions
If you have questions please see instructions below
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1. In the following years, did you have 20 or more employees for 20 or more calendar weeks?
2. In the following years, did your organization participate in a multi or multiple employer Group Health Plan in which there was at least one employer who had 20 or more employees for 20 or more calendar weeks?
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Question 1 | Date Met | Question 2 | |
2024
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2023
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CBEBT is primary through the end of the Current Calendar Year 2018 and through end of the Next Calendar Year 2019; regardless of your employee counts in Previous Calendar Year of the remainder of the Current Calendar Year. |
CBEBT is parimary for all of the Current Calendar Year 2018. Final status for 2019 cannot be determined. |
Medicare is primary for Current Calendar Year 2018, as long as the 20 or more employee for 20 weeks does not become met in the remaining weeks of the Current Calendar Year 2018. Final status for 2019 cannot be determined. |
The weeks do not need to be consecutive.
Employees include full time, part time, intermittent, and/or seasonal.
Current employment is defined as those who receive W2 forms, excluding any independent contractors and religious who are covered under the health plan through their Order. |
List Your Current and Previous Carriers in the Past 5 Years, Explain Reason for Termination or Reason for Bid. |
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