Account Information
Products Being Purchased:
Medical:
Yes
Dental:
No
VisionBlue:
No
Requested Effective Date of Coverage:
1/1/2010 12:00:00 AM
Requested Billing Cycle:
1
Initial Renewal Date:
1/1/2011 12:00:00 AM
Employer Contribution Percent Toward Premium:
Medical:
20
Employer’s Legal Name:
MCPD
Fiscal Year Begins on (MM/DD):
0101
Fiscal Year Ends on (MM/DD):
1231
Benefits are based on:
CalendarYear
Nature of Business:
Nature of Business
Health Benefit Plan Name:
Health Benefit Plan Name
Does the Employer have any current group coverage with BlueCross BlueShield of Tennessee?
No
Current Group Medical Carrier:
None
Are there Subsidiaries under this Group Agreement?
No
Address(es)
Mailing Address
Address Line 1: 11333 N. Scottsdale Road
Address Line 2: Ste 1003
City: Paradise Valley
State: AZ
ZipCode: 85253
County: Maricopa
Physical Address Same as Mailing Address:
Yes
Billing Address Same as Mailing Address:
Yes
Contact Information
Group Administrator
First Name:
Peter
Last Name:
White
Title:
Director
Telephone Number:
6156414444
Extension (if applicable):
Fax Number:
6156413333
Email Address:
ljames@cbent.com
Executive Decision Maker
Same As Group Administrator?
No
First Name:
Karen
Last Name:
Crawford
Title:
Manager
Email Address:
gfalls@cbent.com
Legal Information
Federal Employer Identification Number (FEIN):
951753258
Legal Entity Type:
Corporation
Total number of current employees (full-time, part-time, owners/partners, private contractors):
100
Total number of employees who work a minimum of 30 hours per week (include owners/partners):
100
Total number of employees in preceding year:
100
Does the Employer’s Plan qualify as an ERISA Plan?
No
Is this Coverage part of a Union negotiated Contract?
No
Is this Employer a Minority Owned Business?
No
Is this Employer a Government Contractor?
No
In the past 36 months, has any creditor filed a petition requesting the Employer or any affiliated entity to be placed into bankruptcy?
No
In the past 36 months, has the Employer or any affiliated entity filed for protection or operated under Federal or State bankruptcy laws?
No
ID Card/Web Information
ID Card Information
Initial ID Cards are to be mailed to:
Group
Future ID Cards are to be mailed to:
Group
Web Information
Enrollment changes via the Web are to be Accepted from:
Group
Employee Address Changes via the Web are to be Accepted from:
Group
Coordination of Benefits via the Web are to be Accepted from:
Group
Optional Medical Coverages
Optional Coverage
Include in Option: 1
Behavioral Health Rider: No
Wellcare Rider: No
Optional Services/Programs
COBRA Administration:
Accept with initial notification letter
Will BCBST handle COBRA Administration for non-BCBST Product(s)?
No
Are you offering a BCBST HRA?
No
Are you offering a BCBST FSA?
No
Do you contribute to an HSA?
No