Associated Fire Fighters of Illinois - Insurance Database Online Form

Please complete as many fields as possible - Also, please submit form for as many different Plans your Local has.

Local:                 

Officer Name:  

Date:                       Fiscal Year:

Name of Insurance Company:  

Name of Plan (If Given):             

Type of Plan (PPO/HMO/POS/Self/HSA) :

Monthly Cost of Plan

Single Employee Plan (Complete as much information as you know)

Emp Cost:   Emp Percent:   City Cost:   Total Cost:

Single Employee + CHILD

Emp Cost:   Emp Percent:   City Cost:   Total Cost:

Single + SPOUSE

Emp Cost:   Emp Percent:   City Cost:   Total Cost:

Family Plan

Emp Cost:   Emp Percent:   City Cost:   Total Cost:

Plan Description

% Paid by Insurers:                            Network:           Out of Network:

Annual Max Deductible/Single          Network:           Out of Network:

Annual Max Deductible/Family         Network:           Out of Network:

Max Ann. Out of Pocket/Single         Network:           Out of Network:

Max Ann. Out of Pocket/Family         Network:           Out of Network:    

Dr.'s Office Co-Pay ($$ or %)           Network:            Out of Network:

Maximum Lifetime Benefit                 Network:     Out of Network:

Prescription Costs

Generic Prescription Drug CoPay or % Paid:  

Formulary Prescription Drug CoPay or %:    

Name Brand Prescription Drug CoPay or %:  

Life Insurance

Does your Employer provide Term Life Insurance for the Employee?

If Yes, please provide the face value: