Member Application Form
indicates required fields!
I. Contact Information
Name of Contractor:
Type of Construction:
Home Office Address:
(Max 200 characters)
Mailing Address:
(Max 200 characters)
Main Phone Number:
(for eg.xxx-yyy-zzzz)
Website Address:
(for eg. http://www.google.com)
KEY EXECUTIVES - CEO,COO,CFO and HR MANAGER
A.
PHONE:
FAX:
EMAIL:
(To be remembered in case you forget your password)
B.
PHONE:
FAX:
EMAIL:
C.
PHONE:
FAX:
EMAIL:
D.
PHONE:
FAX:
EMAIL:
indicates the key contact for ACBG discussions.
II. Please describe your Company:
Yes
NO
A.
Privately Owned?
B.
U.S. Owned?
C.
Annual Medical Claims Exceed $750,000?
What is your particular interest in joining ACBG?
(Max 200 characters)
What concerns does your organization have concerning membership in a group captive like ACBG?
(Max 200 characters)
III. Insurance Information
Insurance Company:
Contact Name/Number:
Title:
Insurance Broker:
Company Name:
Contact Name/Number:
Carriers:
Renewal Date:
A.
Stop Loss
B.
Reinsurance Carrier
C.
Medical Insurance
D.
Dental Insurance
E.
Life Insurance
F.
STD/LTD
G.
Vision
H.
3rd Party Wellness Vendor
I.
3rd Party Disease Mgmt. Vendor
IV. General Questions:
Yes
NO
A.
Will you be willing to furnish the information outlined in the attached exhibit A?
B.
The ACBG program is complex and difficult to compare to traditional insurance programs. Will you allow ACBG to prepare a comparison and an analysis of the program to other alternatives?
C.
Will you make a "best effort" to follow the steps in the mutually agreed timeline and complete the steps on a timely basis?
D.
Please outline the ownership of your organization in the paragraph below.
(Max 200 characters)
Submitted by:
Position:
Company Name:
Date:
Signature:
Note:
THIS APPLICATION MUST BE SIGNED BY AN OFFICER OF THE CONTRACTOR ORGANIZATION
This form may also be sent via e-mail to Steve@acbg.net
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Security Code:
Email
Email
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