DVHCC Member Census

CURRENT MEMBERS, PLEASE COMPLETE THIS FORM AS THOROUGHLY AS POSSIBLE TO UPDATE OUR RECORDS. IF YOU REPRESENT MORE THAN ONE MEMBER GROUP, PLEASE FILL OUT SEPARATE FORMS FOR EACH.

THANK YOU FOR YOUR PARTICIPATION.

Organization

Contact Person

Contact Person Name

Contact Person’s Title

Is Contact A Third-Party Administrator?
YesNo

If Yes, TPA Firm

Address

Street Address

City

State

Zip

Phone

Cell/2nd Phone

Fax

E-Mail

Employee Identification Number

Fund Participants

Active Members

Active Members’ Dependents

Retired Members

Retired Members’ Dependents

Total Participants

Consultant/Actuary

Consultant/Actuarial Firm

Medical Carrier

Medical Carrier Name

Insured Or Self-Insured?

Medical Renewal Date

Stop-Loss Provider

Stop-Loss Renewal Date

Typical Hourly Welfare Fund Contribution Rate (in Dollars)

Retiree Medical Carrier

Retiree Medical Carrier Name

Pre-65

Insured Or Self-Insured?

Medicare Eligible

Insured Or Self-Insured?

Pharmacy Benefit Manager

Pharmacy Benefit Manager Name

Insured Or Self-Insured?

Pbm Renewal Date

If You Cover Medicare-Eligible Participants, Are They Enrolled In Either RDS or EGWP Programs?

YesNo

RDS

EGWP

Dental Carrier

Dental Carrier Name

Insured Or Self-Insured?

Dental Renewal Date

Life Insurance Carrier

Life Insurance Carrier Name

Insured Or Self-Insured?

Life Renewal Date

Vision Carrier

Vision Carrier Name

Insured Or Self-Insured?

Vision Renewal Date

Fiduciary Insurance Carrier

Fiduciary Insurance Carrier Name

Fiduciary Insurance Renewal Date

Future Issues You Would Like The Dvhcc To Address

Notes/Additional Information

Phone

DVHCC Member Census

DVHCC About

The Delaware Valley Health Care Coalition, Inc.

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