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Plan Design Questionnaire Group Long Term Disability Insurance
VENDOR NAME:
INSTRUCTIONS: Vendors should download this fillable form from Bonfire BPro, complete, and upload to Bonfire BPro. Vendors are required to review the plan design items herein and indicate “Yes” or “No” or respond, as necessary.
| ITEM |
| LONG TERM DISABILITY INSURANCE BENEFITS |
| VENDOR’S PROPOSE RESPONSE |
| 1. |
| Long Term Disability Benefit: XX % of the first $ XX of Predisability Earnings, reduced by income. |
| %: |
| 2. |
| Long Term Disability Benefit Maximum before reduction by Deductible Income: |
| $: |
| 3. |
| Long Term Disability Benefit Minimum: |
| $: |
| 4. |
| Benefit Waiting Period: |
| 5. |
| Maximum Benefit Period: |
| 6. |
| Briefly describe Vendor’s Evidence of Insurability process. |
| 7. |
| Does the Vendor offer waiver of premium benefits? |
| Y/N |
| 8. |
| Briefly describe Vendor’s definition of Disability. |
| 9. |
| Does the Vendor offer a Return to Work Incentive? If so, briefly describe. |
| 10. |
| Does the Vendor offer a Rehabilitation Plan Provision? If so, please state the increased benefit proposed. |
| 11. |
| Briefly describe how Predisability Earnings are calculated. |
| 12. |
| Does the Vendor offer a Survivors Death Benefit? If so, please describe. |
| 13. |
| List any disabilities excluded from coverage. |
| 14. |
| Does the Vendor’s plan design list any disabilities subject to limited pay periods? If so, please explain. |
| 15. |
| Does the Vendor offer an electronic claim filing system? |
| Y/N |
| 16. |
| Briefly describe the timeline for receiving notice of a decision on a claim. |
| 17. |
| Briefly describe, if claim is approved, how/when payments will be received by the member. |
| 18. |
| Briefly describe the review procedure for denied claims. |
This information should not be factored into proposed price and will not be evaluated toward total point allocation.
Describe any additional products/services Vendor offers.