Information Request: Draft

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.

* Contact Name:
* Organization:
* Number of Employees:
* Address:
* City:
* State:
* Zip Code:
* Telephone Number:
Fax Number:
* Email Address:
How would you prefer we contact you?
* Tax ID Number:

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?
Which benefits interest you?

How did you hear about us?
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:
  1. Answer all questions in the top and bottom sections completely and accurately.
  2. Have the request signed by an individual authorized by the organization to act on its behalf.
  3. Do not cancel your existing coverage until the proposal process is complete.
Nature of Business:
# of Years Organization in Business:
Proposed Effective Date:
Does your deductible reset:

In Month:
Have you, in the last 2 years, ever had less than 20 employees?

Medicare Secondary Payer Questions
If you have questions please see instructions below

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?

Question 1
Date Met
Question 2
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.
    Employee Type / Business Offered

    * What is the classification of employee?
    * What is the number of Eligible Employees for this classification?
    * What is the number of Enrolling Employees for this classification?
    * Are Retirees allowed for this classification?
    * What is the number of months for Extensions?
    * What is the Probation Period for this classification?
    * Do you Contribute towards premium?
    * What is percent you Contribute towards Employees premium?
    * What is percent you Contribute towards Dependents premium?
    * How many hours do you require to be eligible?
    * What coverages will you offer for this classification?
    * Are your employees allowed to choose which Coverage they elect?
    * If more than one location, can your locations choose different coverages from each other?
    * Can the dependents choose different coverages from the employee?
    * Required to add Classification
    Enter all the fields above and press the "Add New Classification" button
    Do you Contribute
    Contrib %
    Contrib %
    Choose Choice of Coverage
    Account Coverage Different
    Dep Coverage Different
    Total Employees
    Please explain anything else about your benefit structure

    Health Information

    Please answer the 5 questions below.
    1. Has any employee/dependent been treated for a serious illness (physical or mental) had more that $5000 of medical expenses; been hospitalized; or had surgery in the past twelve months?
    Please explain why you selected 'Yes' for question number 1
    2. Is any employee/dependent apt to have a continuing disability from any existing mental or physical disorder; including pregnancy?
    Please explain why you selected 'Yes' for question number 2
    3. Has any employee/dependent been advised to have surgery in the last six months or anticipate hospitalization for any other reason?
    Please explain why you selected 'Yes' for question number 3
    4. Are there any employees/dependents who are incapacitated or confined in a hospital or treatment facility?
    Please explain why you selected 'Yes' for question number 4
    5. Are there any employees/dependents who are not actively performing their duties full-time due to a disabling illness or injury?
    Please explain why you selected 'Yes' for question number 5


    When you are contacted by our sales team, please have the following documents available:

    • Current census of all eligible employees indicating those currently insured and type of coverage (employee / spouse / child / family / waiver). Census must include dates of birth or ages, gender, occupation, current salary or wage, and zip code.
    • Current benefit plan documents or plan summaries.
    • Current premium statement.
    • A copy of your most recent renewal. Include renewal current and prior rate history, and all applicable claims experiences for the past 3 years.

    Important - Please Read Carefully

    The organization certifies that the information above is complete and accurate. The organization shall notify the Trust promptly of any changes in this information that may affect the eligibility of employees or their dependents, including the additions of any newly eligible employees or dependents. The Trust shall be entitled to rely on the most current information in its possession regarding eligibility of employees and their dependents in providing coverage under this Agreement.

    * Signature:
    Type your name to affirm your signature