How to Join

Find Your Path Forward

The IAFF Health & Wellness Trust is available to collectively bargained IAFF Participating Locals working for a public employer. If you would like to learn more but are not ready to request a proposal, please complete the required fields below and submit. If you are ready to request a proposal, please complete the entire form and the Trust Consultant will work with you to create a proposal for your Local.

Questionnaire and Information Request

Local Name(Required)

Local Number(Required)

State

Primary Contact Name(Required)

First Last

Contact Phone(Required)

Contact Email(Required)

Desired Effective Date (approx.)

Dates of Current CBA:

Briefly describe your timeline for bargaining

Total full-time Fire Department Employees?

# of Bargained Employees:

# of Non-Bargained:

Employer Type (City, County, Fire District, etc.)?

Are you a Public or Private Entity?

What coverage lines are you interested in? (Medical, Dental, Vision, etc.)

Current Plan Information

When does your current plan renew?

Current Healthcare Contributions (Employer and Employee contributions):

Employee Only Coverage: Employer Pays

(% or $)

Employee Pays

(% or $)

Dependent Coverage: Employer Pays

(% or $)

Employee Pays

(% or $)

How many employees (approx.) fall into each of the following categories? (If composite rate, use line 6.)

1. Employee Only (EE):

2. Employee & Spouse (ES):

3. Employee & 1 Child (EC1):

4. Employee & 2+ Children (EC2):

5. Employee, Spouse & 1 Child (ESC1):

6. Employee, Spouse & 2+ Children (ESC2):

Is there an Employer contribution toward an HSA/HRA/VEBA or similar? If so, what is it:

Are retirees currently covered on your Employer-sponsored plan?

If yes, how many fire department retirees are covered: Non-Medicare:

Medicare:

If yes, does the Employer contribute toward the cost and how much?

Please send the following documentation for all plans for which you would like to receive an IAFF HWT pricing proposal with your response:

Census – Employees and Dependents including:

Date of Birth
Gender
Zip Code
Employment Status
Coverage Type (Employee only, Employee & Spouse, Full Family, etc)

Census

Max. file size: 10 MB.

Copy of your current plan booklet or a summary for all plan(s)

Max. file size: 10 MB.

Current premiums or monthly plan costs

Max. file size: 10 MB.

3-year rate history

Max. file size: 100 MB.

A copy of your most recent renewal for your current plan(s)

Max. file size: 10 MB.

• Current and prior year large claimant reports with prognosis and diagnosis (if available)

Max. file size: 10 MB.

Current and prior year Claims Utilization – premium vs. claims, month-by-month (if available and preferable with fire department split out from the rest of the City, County, or Township)

Max. file size: 10 MB.

Is there anything else we should know about your current plan or your future goals?

Please don’t hesitate to contact the Trust Consultants at DiMartino Associates with any questions or concerns about this Questionnaire.

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