Aetna Validation Form – Fill Out and Use This PDF

Contractual Validation Form - Atlanta

HMO/QPOS (Two-Nine Eligible Lives)

(This form must accompany all new case submissions. All information must be submitted 30 days prior to the effective date to ensure ID cards are received prior to effective date.)

Aetna U.S. Healthcare - Small Business Center

841 PRUDENTIAL DRIVE, 6TH FLOOR WEST, F602 JACKSONVILLE, FL 32207

PHONE: (800) 223-2125 FAX: (800) 814-5677

New Business Case Information:

If any of the information listed below is excluded or incomplete when the case is

submitted, all materials will be returned to the producer for completion.

Required documentation for new business case installation:

Employer master application

Employee individual application

Employer Verification Form Note: must be signed by employer.

Original copy of completed Individual Health Statement for each employee.

If group coverage currently exists, copy of recent prior carrier bill. Individuals on the bill should match those listed on the wage and tax statement

Copy of most recent calendar year wage and tax statement containing the names, salaries, etc. of all employees of the employer group. Employees who have terminated and work part time must be noted Copy of rate quote(s) including:

•Complete proposal including rate and plan design

•Employer signature on signable rate page and supporting rate documentation Rates must match the enrollment reported and effective date. If discrepancy exists please include documentation to support the discrepancy

COPY of binder check and completed Binder Submission Form. Send originals to address on form.

Broker of Record letter and commission forms

Additional Information:

How many employees are enrolled in the current employer sponsored medical plan; or if no prior coverage exists, how many employees are likely to enroll in this plan? ________

How many eligible employees are not expected to enroll because they have spousal or individual coverage? _____

Do all eligible employees work 25 hours or more? oYes oNo

What percentage of the cost of the plan will the employer contribute? Employee only _____% Dependent ____%

ATLANTA HMO/QPOS 2-9 CVF (05/04/2001