Health Risk Evaluation Form

Section I - Employer Data
*
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
*
Total Number of Eligible Employees: *
Total Enrolled Employees: *
Employer Contribution: *
  
*
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:
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. Y N
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.