Beginning with January-2013 effective dates, Spectrum will require completion of Plan Participant Disclosure Statements on new-business sold cases where individual participant claims experience is unavailable.

This additional disclosure information is required only when individual participant claims experience is unavailable (e.g., small fully-insured employers) and is intended to supplement the Plan Sponsor Disclosure Statement that is also required on all newly-sold cases.  Information obtained from these statements is vital to the final sold-case underwriting process on groups without individual participant claims experience, and can also be a valuable tool to the employer when evaluating self-funding as a benefit financing option.

Requirement Parameters

  • Plan Participant Disclosure Statements are required on all new-business sold cases where individual participant claims experience is unavailable.
  • Plan Participant Disclosure Statements must be completed, signed and dated by all employees no sooner than three (3) months prior to the proposed effective date of the stop loss coverage.
  • If other, similar forms (i.e., from another carrier) have already been completed by all employees, Spectrum will accept those forms provided they are current to within three (3) months of the proposed effective date of the stop loss coverage.
  • Plan Participant Disclosure Statements may be submitted at any time during the underwriting process, but are not required until the final sold-case underwriting process as a supplement to the Plan Sponsor Disclosure Statement.  From a timing standpoint, Spectrum strongly recommends that these participant forms be submitted in conjunction with the Plan Sponsor Disclosure Statement.
  • If submitted at any time after the initial quote is released, stop loss terms may be revised.

The Plan Participant Disclosure Statement will be used to accurately assess the risk characteristics of the employer group.  The form is just one page and is divided into several sections, as follows:

  • General Employee Information
  • Covered Dependent Information
  • Medical Information (for the employee and its dependents)
    • Details required include:
      • Name of person referenced.
      • Medical condition.
      • Current and past treatment including medications and/or prescriptions.
      • Date range to include date of diagnosis and date of last treatment and/or medication/prescription.
      • Prognosis and status of the condition and if the condition ongoing.
  • Declaration of Completeness and Accuracy with Signature and Date

If you would like a PDF copy of the Plan Participant Disclosure Statement and instructions for completion, please contact us at 317-692-3285 or email us by clicking here.