Group Health Risk Evaluation Form: The Hoffman Group

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Section I - Employer Data
Employer Name:	*
Business Phone:	*
Tax ID Number:	*
Years in Business:	*
Address:	*
City:	*
County:	*

State:	*
ZIP:	*
Nature of Business:	*
Subsidiaries:	*
Company Contact:	*
Email Address:	*
Website:

Section II - Carrier History
Carrier	Plan Type	Effective Date	Term Date	Single	E+Sp	E+1CH	E+CH	Family

Section III - Eligibility
Number of Full Time Employees:	*
Total Number of Eligible Employees:	*
Total Enrolled Employees:	*
Employer Contribution:	*


Part Time Employees:	*
Ineligible Employees:	*
COBRA Participants:	*

Section IV – Medical Profile

To the best of your knowledge, please indicate any members participating in your health insurance program who have experienced any of the following conditions within the last 12 months:

Health Risk Evaluation:

Heart Disease

Stroke

Diabetes

Seizures

Kidney Disease/Failure

Back Disorders

Chronic Lung Disorder

Cancer

AIDS/HIV

Drug/Alcohol Abuse

Mental/Nervous Disorders

Muscular Dystrophy

Multiple Sclerosis

Lupus

Rheumatoid Arthritis

Congenital Disorders

Growth Hormones

Intestinal Disorders

Liver Disorders

Organ Transplants

Connective Tissue Disorder

If any of the above boxes were checked, please explain below:

To the best of your knowledge...	Y	N
1. Are any covered members currently pregnant?
If so, Due Dates:
2. Have any covered members been hospitalized in the last 5 years?
3. Have any employees been absent from work for more than 10 consecutive days?
4. Have any covered members been advised to have surgery or undergo treatment?
5. Are any covered members currently receiving Worker Comp or SSI?

If you answered “YES” to any of the preceding medical questions, please provide as much detail as possible in the spaces below:

Q#	Emp.	Dep.	Age	Dates of Treatment	Date of Recovery	Nature of Condition	$ Amount of Claims	Prognosis Current Status

Section V – Service Questionnaire – The Hoffman Group

Please respond to the service you’ve received fromThe Hoffman Group over the last 12 months.

1. Is your Account Manager responsive to your needs?

If no, please explain:

2. Have you visited our Website? www.thehoffmangrp.com

3. Would you be interested in a monthly wellness email?

4. Can we list you as a reference for future prospective clients?

If no, please explain:

5. Are there any other benefits you would be interested in looking at? If yes, please choose below.

Group Life	Vol. Life	Dental
LTD	Vol. LTD	Vision
STD	Vol. STD	401(k)
P&C	Auto	Home

If you have an electronic version of your census data, please browse for the file here and attach it to this request form:

Thank you for taking a moment to complete this form. It will be very helpful as we begin to market your plan for the upcoming renewal. Please note: This information is only to be used in marketing your health insurance program. We will only share with other vendors what is necessary in accordance with HIPAA.

By submitting this form, you agree that this is accurate and complete to the best of your knowledge.

2 Berea Commons, Suite 10
Berea, Ohio 44017

1.800.826.4006

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Elyria, Ohio 44035

4634 Bit & Spur Road

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1418 Town Center Blvd.
Brunswick, Ohio 44212