Small Employer Cover Sheet and Checklist Aetna Small Group Underwriting New Business Case 841 Prudential Drive, F434 Jacksonville, FL 32207 Phone: 1-888-380-7821 ● Fax: 1-866-548-9839 Case Name Date Submitted (MM/DD/YY) Proposed Effective Date (MM/DD/YY) Submission Date Aetna must receive all new cases with 2 to 50 employees on or before the requested effective date. If a cut-off deadline occurs on a weekend, we need to receive all new cases sold on the preceding Friday. If incomplete information is provided or the submission is not complete until after the cut-off date, we may assign the case a later effective date. U U Required for New Business Employer Master Application – Must be fully completed, signed and dated by employer. Employee Enrollment/Change Form/Medical Questionnaire – (Illinois Standard Health Employee Application for Small Employees – state-mandated universal form) – Fully completed and signed by each employee enrolling/waiving coverage and any continues. Employees waiving/declining coverage must complete the waiver section of the Enrollment/Change Form. Employees waiving coverage must complete the reason for waiving coverage on the Employee Enrollment Form. Copy of most recent Quarterly Wage and Tax Statement (QWTS) containing the names, salaries, etc. of all employees of the employer group. Employees who have terminated, work part time, are seasonal, etc. must be noted accordingly on the QWTS. Terminated employees must have the date of termination listed on the QWTS. Handwritten comments must be signed and dated by the employer. Newly hired employees not listed on the QWTS must provide the first and last month’s payroll stub and registry/summary for each employee. Sole proprietors, partners or corporate officers not reported on the Quarterly Wage and Tax Statement must submit a completed Small Employer (2-50) Proof of Eligibility Form. Also, as identified on the form, additional supporting tax documentation must be submitted. Request and complete this form prior to submission to Underwriting. When submitting, include the additional supporting tax documentation. If group coverage currently exists, provide a copy of the most recent prior carrier bill. Individuals contained on the bill should match those listed on the QWTS. If not, please indicate on the bill why they are not on the QWTS. The initial premium check for the first month’s medical, dental, STD and life premiums must be included and payable to “Aetna Inc." (Aetna’s receipt of the check does not guarantee acceptance of the group.) Copy of the sold proposal must be included, including rates and plan design(s). Before submission, verify contribution and participation requirements by product. General Information If applying for PPO or indemnity medical, please list the prior carrier’s individual deductible: $ U If applying for dental, does dental coverage currently exist? YES NO If YES and prior plan includes orthodontia, please provide the prior plan’s ortho max: $ U Please note that additional documentation may be required (common ownership, newly formed business, etc.). Is employer, plan sponsor or a third party funding any of the deductible? YES NO If YES, how much? $ U Does this group have a flex plan under Section 125 of the Internal Revenue Service Code? YES NO Broker and/or General Agent Authorization Broker Signature Date (MM/DD/YY) General Agent Signature Date (MM/DD/YY) This submission does not constitute approval. Please do not cancel or change your existing health coverage until you receive formal approval from Aetna. GR- 68724 (8-11)