• 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