REQUEST FOR KEREON CDHP PROPOSAL
Kereon HSA, Inc., 13700 Watertower Circle, Suite D, Plymouth, MN 55441-3705

All information is necessary to calculate the Analyzer. Information with an Asterisk * is required to submit form. Once this form is received, a Kereon representative will contact you.
Please include rates and summary plan descriptions for all current and proposed plans.
 
Today's Date
Plan Delivered Date
Your Email*
Plan Renew Date
Current Year Calendar Plan
Proposed Year Calendar Plan
 
Company Name (specify if dba)
C Corp     Sub S     Partner  
Owner Name(s)
CEO
CFO
Address/City/State/Zip
Owner's Main Phone
Owner's Email
Key Contact Personnel
Position
Key Contact Phone + Ext
Location
Key Contact Email
Co. Web Site
 
Consultant/Agent Company
Consultant/Agent (C/A) Name
Address/City/State/Zip
C/A Main Phone
C/A Email
Key Contact Personnel
Position
Contact Phone + Extension
Location
Contact Personnel Email
C/A Web Site
Are you currently Agent of Record with this Company?     Yes    No
 
Edibility/Census
Current
Proposed
Total Number of EE
FT
PT
FT
PT
Total EE Electing Coverage
Total Electing EE Only
Total Electing EE+Dep
Total Electing EE+Spouse
Total Electing EE+Family
 
Migration and Trend
Will this Plan be a Universal Install (Entire Group), or an Option with Other Plans?
 

Yes - Universal Install with 100% migration
Quoted as an option, but will not replace any current plans
Quoted as an option, and will replace plan (plan name)

Expected Migration to CDHP Plan (complete for option plans only)
Unknown - please quote low and high expected migration examples/or
Please quote annual expected migration (percentage of EE remaining in current plan versus moving to a CDHP) as:
1. % Year One        2. % Year Two        3. % Year Three
4. % Year Four        5. % Year Five

 
Summary of Benefits
Current
Proposed
Health Plan Name & #
Deductible: EE
Single
Family
Single
Family
Coinsurance: EE
Single
Family
Single
Family
Co-pay Per
OV
ER
Rx
OV
ER
Rx
Coverage Type
Self Funded
Fully Insured
Self Funded
Fully Insured
Additional Plans - Please attach if possible
FSA
HSA
HRA
Other
FSA
HSA
HRA
HRA/HSA
Premium or Premium Equivalency or COBRA (% or $ amount)
ER Health Plan Monthly Contribution
EE
EE+Sp
EE+Dep
EE+Fam
EE
EE+Sp
EE+Dep
EE+Fam
EE Health Plan Monthly Contribution
EE
EE+Sp
EE+Dep
EE+Fam
EE
EE+Sp
EE+Dep
EE+Fam
COBRA Rates
EE
EE+Sp
EE+Dep
EE+Fam
EE
EE+Sp
EE+Dep
EE+Fam
ER Sec. 125 Matching Contribution (Ex:ER matches $1 for EE $2 = 33%)
Single %
Family %
Single %
Family %
Proposal Type Requested - Request Kereon's recommendation, or choose a plan:

Request Kereon Recommend Custom Blended CDHP
CDHP HSA
CDHP HRA
CDHP HRA/HSA Blend: $ Annual Fixed HSA or $ Annual Variable HRA
ER HRA Contribution
EE
EE+Sp
EE+Dep
EE+Fam
EE
EE+Sp
EE+Dep
EE+Fam
ER HSA Contribution
Matching
Fixed
Single
Family
Matching
Fixed
Single
Family
Max Out Of Pocket (MOOP) In Network
Single
Family
Single
Family
Is Deductible included in MOOP?
Yes  No
Yes  No
Is there any additional information you would like us to know?