Phone

(215) 676-7940

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

    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