Forms and Guides

Employer Stop Loss in NY

Claim and Reporting Requirements

Specific Stop Loss: an initial notice of claim and a request for reimbursement must be sent to receive payment for a claim that has reached the Specific deductible. See the instructions below for more information regarding these requirements.

Aggregate Stop Loss: an Aggregate Report is required at the end of each month for groups with aggregate coverage. An Excel report template with auto calculation helps make this process easy. See the instructions below for more information on the reporting requirement as well as when claims should be submitted.

Stop Loss Claim and Reporting Instructions (PDF)
Specific Stop Loss Claim Form (Word)
Stop Loss Monthly Aggregate Report Template (XLS)
Aggregate Stop Loss Claim Form (Word)