"Annual Peo Certification Form" - Connecticut

Annual Peo Certification Form is a legal document that was released by the Connecticut Insurance Department - a government authority operating within Connecticut.

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Download "Annual Peo Certification Form" - Connecticut

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STATE OF CONNECTICUT INSURANCE DEPARTMENT
ANNUAL PEO CERTIFICATION
COMPANY NAME: ___________________________________________________________________
(A SEPARATE FORM MUST BE COMPLETED FOR EACH COMPANY NAME)
COMPANY ADDRESS: ________________________________________________________________
NAIC #:
_________________________________________________________________
List all PEOs for which the company is providing a large group health insurance product. Please indicate
those that are fully integrated and whether they have submitted certification with the application for
coverage that they have achieved, and will continue to maintain throughout the term of the underlying
insurance policy, fully integrated co-employer status with each participant enrolled under the policy as
determined by applicable state and federal laws, rules and regulations.
PEO NAME
FULLY
SUBMITTED
INTEGRATED
CERTIFICATION
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
List all PEOs for which the company is providing large group self-funded administration. Please indicate
those that are fully integrated and whether they have submitted certification with the application for
coverage that they have achieved, and will continue to maintain throughout the term of the underlying
insurance contract, fully integrated co-employer status with each participant enrolled under the contract as
determined by applicable state and federal laws, rules and regulations.
PEO NAME
FULLY
SUBMITTED
INTEGRATED
CERTIFICATION
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
STATE OF CONNECTICUT INSURANCE DEPARTMENT
ANNUAL PEO CERTIFICATION
COMPANY NAME: ___________________________________________________________________
(A SEPARATE FORM MUST BE COMPLETED FOR EACH COMPANY NAME)
COMPANY ADDRESS: ________________________________________________________________
NAIC #:
_________________________________________________________________
List all PEOs for which the company is providing a large group health insurance product. Please indicate
those that are fully integrated and whether they have submitted certification with the application for
coverage that they have achieved, and will continue to maintain throughout the term of the underlying
insurance policy, fully integrated co-employer status with each participant enrolled under the policy as
determined by applicable state and federal laws, rules and regulations.
PEO NAME
FULLY
SUBMITTED
INTEGRATED
CERTIFICATION
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
List all PEOs for which the company is providing large group self-funded administration. Please indicate
those that are fully integrated and whether they have submitted certification with the application for
coverage that they have achieved, and will continue to maintain throughout the term of the underlying
insurance contract, fully integrated co-employer status with each participant enrolled under the contract as
determined by applicable state and federal laws, rules and regulations.
PEO NAME
FULLY
SUBMITTED
INTEGRATED
CERTIFICATION
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
_______________________
[ ]
[ ]
I, _____________________________, _______________________of _________________________,
(Printed Name)
(Title)
(Company or Organization)
hereby certify that the information above is true and accurate.
____________________________________________ DATE SIGNED: _________________________
OFFICER’S SIGNATURE
IN WITNESS WHEREOF, the undersigned has affixed his/her signature this ___ day of ______, 200__.
_____________________________
Certification must be submitted annually on or before January 31 to:
State of Connecticut Insurance Department
Attn: Life & Health Division
P O Box 816
Hartford, CT 06142-0816
PEO HEALTH INSURANCE NOTICE FORM
IMPORTANT INFORMATION ABOUT YOUR HEALTH INSURANCE
Your employer has contracted with
(name of PEO)
to provide
outsourced human resources functions as a Professional Employer Organization (“PEO”). A
PEO provides integrated services to manage human resource responsibilities and employer risks
for clients. The PEO delivers these services by establishing and maintaining an employer
relationship with the employees at the client's worksite and by contractually assuming certain
employer rights, responsibilities, and risk including health benefits administration. The PEO
relationship involves a contractual allocation and sharing of employer responsibilities between
the PEO and the client. This shared employment relationship is called co-employment, and under
this relationship, you are considered to be not only an employee of
(name of small
employer client company)
but also
(name of PEO)
.
Because of this co-employment relationship, your health insurance is now provided to
you as an employee of
(name of PEO)
rather than
(name of small employer
group)
. Because your health insurance is provided through a large employer group,
defined in Connecticut as 51 or more employees, the small group employer insurance laws and
protections no longer apply to your coverage. Specifically, this means the following:
For your small group employer:
Small group health insurance laws in Connecticut require insurance carriers who
provide small group health insurance to Connecticut employers to provide that insurance
on a guaranteed issue, guaranteed renewability basis with premium rates based on
community rating. By establishing a co-employment relationship, the health insurance is
no longer issued to a small group and those guaranteed benefits are lost. Should the PEO
relationship be terminated, health insurance replacement will likely cost considerably
more.
For the small group employee:
All aspects of the health insurance will be controlled by the PEO, including plan
design, carrier selection, eligibility, plan termination, and regulatory compliance. Should
the relationship between your small group employer and the PEO terminate, there could
be issues with respect to continuation of coverage and transition of care, particularly for
those confined on the date of termination. The current benefit plan design may not be
available in the small employer market.
Please make certain you understand your rights and obligations as an employee receiving health
insurance through a co-employment relationship. If you have questions, you should ask
(name
of PEO)
and
(name of small employer)
for more information.
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