Hammurabi

Account Information

(Step 1/6)

Effective Date:

Account Zip:

Broker Target:

Months In Contract:

Expiration Date:

SIC:

Specific Aggregate Deductible:

Total Lives

Account Information:

(Step 2/6)

Specific Deductible:

Aggregate Contract Type:

Current Aggregate Gross Premium:

Specific Contract:

Current Specific Gross Annual Premium:

Currently Self Funded:

Claim Administrator Name:

Current Premium:

Census List:

(Step 3/6)

Enrollee Count:

Enrollee Covered:

Total Lives Covered:

Proposal:

(Step 4/6)

Covered Benefits:

Annual Specific Deductible per Individual:

Estimated Annual Premium:

Annual Aggregate Deductible:

Minimum Aggregate Deductible:

Estimated Annual Premium Aggregate:

Plan Information:

(Step 5/6)

Plan :

If Run In, note months :

If Run out, note months :

Annual Maximum Incl attachment point ($):

Calendar year deductible ($):

Coverage for next $5000 (%):

EE OOP max (incl deductible):

Industry:

Client Information:

(Step 6/6)

Dependent Participation Rate:

Annual Stop Loss limit:

Rates beginning:

Individual Attachment Point ($):

Type of UW:

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