Benefit Program
Competitive Pricing
Comprehensive Products
Consolidated Administration
Worksite Wellness Program 

Mount Vernon Chamber of Commerce Proposal Request Form

Mount Vernon Chamber of Commerce
 Benefit Program Provided Through:

This benefit program provides highly competitive group rates through contracts with the largest and most respected insurance carriers in the state of Washington.

Benefits are offered to member companies from 2 to 149 employees.

Ask your broker for a proposal through the Mount Vernon Chamber of Commerce, or contact Karen Mills, Membership Director at:
Phone: (360) 428-8547
Fax: 360-424-6237

Plan descriptions are available at: http://www.businesshealthtrust.com/

Chamber member companies can access the following insurance programs through the Business Health Trust.

Why You Should Join Mount Vernon Chamber of Commerce Benefit Program

  • Competitive prices through "large group" buying power
  • Ease of administration with consolidated service through Benefit Administration Company
  • Comprehensive benefits for groups from 2 to 149 employees
  • Discounted section 125 (flex plan) services
  • COBRA administration
  • Electronic fulfillment including plan booklets, summaries, and forms
  • Wellness programs that can increase productivity and lower absenteeism,
    which can have a direct impact on the cost of providing healthcare benefits.

Benefit Coverage Provided By:

  • Regence BlueShield
  • Group Health Options, Inc.
  • Washington Dental Services
  • Dental Health Services
  • Vision Service Plan
  • Regence Life and Health
  • Chartis Property Casualty Company
  • WellSpring Family Services
  • 21st Century Legal Plan

Medical Insurance

Regence BlueShield
- Progressive Plan: $0, $200, $500, and $650 deductible options
- Infinity Plan: $200, $300, $500, $1,000, $2,000 and $3,000 deductible options
- Choice of 4 prescription drug plans
- HSA Plan: $1,500 and $2,500 deductible options

Wellness programs included with medical:
- Care enhance - Case management
- Health coaching - Special beginnings

Group Health Options, Inc.
- Alliant Plus $200 Balance Plan
- Alliant Plus $500 Mid Plan
- Alliant Plus $1,000 Balance Plan
- Alliant Plus $3,000 50/50 Plan

Benefits included with medical insurance at no additional charge:
Regence Life and Health
- 15,000 of Basic Life & AD&D

Chartis Property Casualty Company
-10,000 Business Travel Accident coverage

Dental Insurance
Washington Dental Services
- Available for groups from 2 to 149 employees
- PPO plans with up to $2,500 annual maximum
- Family orthodontia option

Dental Health Services
- Available for groups from 1 to 149 employees
- Highly affordable copay plans
- No waiting periods; no deductibles

 

 

 

 

 

 

 

 

 

 

 Vision Insurance
Vision Service Plan
- Available for groups from 3 to 149 employees
- Free eye exam every 12 months

Basic Life & AD&D Insurance
Regence Life and Health
- Buy up options available for groups from 5 to 149 employees
- $50.000, 1x salary to $100,000 and 2x salary to 200,000

Supplemental Life & AD&D Insurance
Regence Life and Health
- Available for groups from 5 to 149 employees
- Up to a maximum $200,000 benefit
- Spouse coverage available

Long Term Disability Insurance
Regence Life and Health
- Available for groups from 5 to 149 employees
- Choice of waiting period

Personal Accident Insurace
Chartis Property Casualty Company
- A voluntary personal accident coverage with 24-hour, worldwide protection.

Employee Assistance Program
WellSpring Family Services
- 24-hour, worldwide protection
- Face to face assessment sessions

Legal Plan
21st Century Legal Plan
- Inexpensive and east access to an attorney for your personal legal needs.

 

 

Program Management provided by:
Wells Fargo Insurance Services USA, Inc.
Health Trust - Proposal Request Form
Fields marked * are mandatory.
Group Legal Name
SIC Code
Company Website
Address (Street, City, State Zip)
Business Description
Years in Business
Requested Effective Date
Current Renewal Date Medical
Current Renewal Date Dental
Is group currently an active dues member of the BWCCI?
YesNo
Employer Premium Contribution (Minimum 75%/0%) for Employee?
Employer Premium Contribution for Dependants:
Current Benefits - Medical
Current Medical Carrier
How long with this carrier?
Medical Plan Design
Co-insurance:
Prev. Care:
Individual Deductible:
Family Deductible:
Out of pocket max: Individual:
Out of pocket max: Family:
Office Visit Copay:
Prescriptions:
Riders:
Current Benefits - Dental
Current Dental Carrier:
How long with this carrier?
Individual Deductible:
Family Deductible:
Waived for P/D?
YesNo
Annual Maximum:
Orthodontia included?
YesNo
Coinsurance: Preventive & Diagnostic: %
Basic Services: %
Major Services: %
Current Benefits - Vision
Current Vision Carrier:
Frequency of Coverage (Exam/Lens/Frames)
12/12/12/
12/12/24
24/24/24
Current Rates
Current Rates - Employee (Enter Medical, Medical, Dental, Vision)
Current Rates - EE/Spouse (Enter Medical, Medical, Dental, Vision)
Current Rates - EE/Child(ren) (Enter Medical, Medical, Dental, Vision)
Current Rates - EE/Family (Enter Medical, Medical, Dental, Vision)
Renewal Rates
Renewal Rates - Employee (Enter Medical, Medical, Dental, Vision)
Renewal Rates - EE/Spouse (Enter Medical, Medical, Dental, Vision)
Renewal Rates - EE/Child(ren) (Enter Medical, Medical, Dental, Vision)
Renewal Rates - EE/Family (Enter Medical, Medical, Dental, Vision)
Quotes will be submitted directly to the Chamber Benefits Team unless otherwise noted in the space. Specify Agency Name
Return quote to:
Email:
Census Instructions
List all employees who are eligible or who will be eligible on the requested effective date of coverage. Employees with valid waivers can be omitted. Please provide all the census date as required below. Please Note: Rates are determined in part by dependent coverage. Please be as accurate as possible or your rate could be affected. Participation must equate to 75% or greater of the eligible employee population (valid waivers excluded).
Please Upload a List of all eligible employees
Click here to download the document. Please complete the document, then save it and upload it here
File Types - jpeg,jpg,gif,bmp,pdf,doc,docx,csv,xls,xlsx
Maximum Limit - 10 MB per file/attachment
Health Risk Questionnaire
This form will not be accepted without all questions being answered. If an answer is zero ("0"), then include that in the field. If the group or the agent has no knowledge of the information being requested, then include "not available" in the comment field of each such question. This form must be signed by both the agent and the group representative. If the questionnaire is completed over the phone, we will accept the name and title of group representative and that it was a phone interview in lieu of the signature.
Do you have a drug/alcohol screening
Please check any of the following your company provides
Cholesterol Screenings
On-Site Flu Shots
Blood Glucose Screenings
Blood Pressure Checks
How many employees are currently on or have been on medical or FMLA leave of absence or are absent from work for medical reasons for more than 3 consecutive workdays during the past 6 months?
How many participants or covered dependents are pregnant?
If any, projected delivery date(s)
Has any participant or covered dependent been treated for or is expected to be treated for a serious illness or injury (e.g.,cancer, AIDS, cardiovascular diseases, renal disease, pulmonary disease, etc)? If so, please clarify with dates, prognosis, follow-up, on going treatments, etc.
Has any participant or covered dependent been treated for or is expected to be treated for an ongoing illness (e.g., juvenile diabetes, substance abuse, mental illness, multiple sclerosis, rheumatoid arthritis, etc.)? If so, please clarify with dates, prognosis, follow-up, on-going treatments, etc.
How many persons are presently covered under the Continuation of medical Benefits as defined under COBRA who will probably continue coverage under this plan?
Has any participant or covered dependent had in the past 12 months or expect to have in the next 12 months a health claim of $10,000 or more? If you are unsure as to the cost of the individual's potential medical expenses, please list the conditions to the best of your knowledge. If so, please clarify with dates, prognosis, follow-up, on-going treatments, etc.
I have provided these answers as part of the application procedure required by Business Health Trust and I certify that all information completed on this form is true, correct, and complete. I understand that Business Health Trust will rely on each answer in making coverage and rating determinations. If Business Health Trust issues a Contract with the Group and then finds untrue, incorrect, or incomplete information has been provided, and if as a result of correcting false information the Group no longer qualifies for the Rate quote, I understand that Business Health Trust will have the right to adjust the rates.
Group Representative Signature/Date (please type your name as signature)
Access Code
Please Enter the Access Code *