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Building a better
health care solution

 
 

Ensurex Charter Enrollment

To participate in the MABX Ensurex Health Insurance Exchange open invitation phase, please complete the employer risk appraisal form below. There is no obligation during the open invitation phase.

This questionnaire is designed to provide information specific to your group and will be used by Ensurex in evaluating risk characteristics to more accurately establish rates, benefits, and eligibility rules as part of your application for coverage.

For the "Health Information" sections, provide the answers to the following questions as they pertain to all eligible employees and/or covered dependents (including COBRA, any state continuation programs, and eligible retirees).  To your knowledge has any person (employee and/or employee’s dependents, or COBRA individuals) who would be covered been diagnosed or treated by a provider for any of the listed conditions within the last five years?

If more space is need to answer any questions, or for assistance, contact Matt Scott at matt@ensurex.co or 717-724-0718.

I. General information
First name*
Last name*
Middle name
Company*
Company size (employees)*
Company Type*
Company address*
City*
State*
Zip code*
Email address*
Phone number*
MABX member*
II. Health Information
1. Cancer*
# of people
Type (if known)
2. Heart disease*
# of people
3. Organ transplant (planned or past)*
# of people
4. Arthritis*
# of people
5. Asthma, emphysema, cystic fibrosis or other lung disease*
# of people
6. Diabetes*
# of people
Type (if known)
7. Epilepsy/seizure disorder*
# of people
8. Disorder of the spine, back, joints or bones*
# of people
9. Stroke, paralysis*
# of people
10. Kidney or bladder disease, kidney dialysis*
# of people
11. Liver disease or hepatitis*
# of people
Type (if known):
12. Multiple sclerosis, muscular dystrophy or cerebral palsy*
# of people
13. Psychological or other mental disorder*
# of people
14. HIV/AIDS*
# of people
15. Tuberculosis*
# of people
16. Colitis or Crohn's disease*
# of people
17. Any condition or disease not mentioned above, or anticipated surgery*
# of people
III. Health Information (part 2)
1.) Have any employees, dependents, or COBRA individuals who are eligible for coverage incurred claims that have exceeded $10,000 (medical and/or pharmacy) during the last 12 months? (If "Yes," please explain in #4 below)*
2. Are any employees currently disabled or otherwise not actively-at-work? (Give medical details and
date disability started in #4.)*
3. Are any eligible employees or dependents currently pregnant?*
How many?
Ages
Due Dates
4. Please explain any "YES" answers in this space. Please indicate what question you are answering. If more space is needed, email matt@midatlanticbx.com.*
Submit
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Pennsylvania New Jersey Delaware Maryland
717-234-3255 856-673-1984 302-533-2510 410-864-8089
Pennsylvania New Jersey Delaware Maryland
717-234-3255 856-673-1984 302-533-2510 410-864-8089