Forms

Claim Forms

• Request for Specific Excess Loss Reimbursement
• Prospective Claim Notification
• Request for Aggregate Reimbursement
  Email or Fax submissions to Deb Loyer
  dloyer at eliteuw dot com
  610.280.4299 (fax)

TPA Forms

• SIIA Questionnaire
  Email or Fax submissions to Steve Santacroce
  ssantacroce at eliteuw dot com
  610.280.4299 (fax)

Other Forms

• Stop-Loss Request for Proposal (RFP)
• MGU Premium Remittance Report
  Email or Fax submissions to Ted Parsons
  tparsons at eliteuw dot com
  610.280.4298 (fax)
• Independent Broker’s Agreement
• W-9
  Email or Fax submissions to Theresa Morris
  tmorris at eliteuw dot com
  610.280.4298 (fax)

Instructions

• Stop-Loss Administrative Guide
• Guide to Identifying Trigger Diagnosis
• High Cost Pharmaceuticals
• Aggregate Claim Request Instructions
• Instructions for Prospective Claim Notification
• Reports Required for Aggregate