Ins 3.33(5)(a)(a) Insurers offering individual major medical health insurance policies or certificates must include a statement on the first page of the policy that the policy is guaranteed renewable except for the reasons stated s. 632.7495 (2), Stats. Ins 3.33(5)(b)(b) Insurers must include authorizations, releases, and notices compliant with state and federal law filed with the office as separate forms that will be presented with the individual uniform application but not considered a part of the application. Ins 3.33(5)(c)(c) Insurers may file a separate form information or election options for the applicant to select deductible, copayment, and coinsurance levels and elect, if applicable, provider networks. Additionally, insurers may include in the form premium payment options for the applicant to select. Ins 3.33(6)(6) Underwriting. Insurers shall comply with the provisions of s. Ins 3.28, including the requirement to return an accepted application as described in s. Ins 3.28 (5) (d), when underwriting a submitted individual uniform application. Ins 3.33 NoteNote: This section first applies to policies issued after July 1, 2010.
Ins 3.33 HistoryHistory: CR 10-068: cr. Register December 2010 No. 660, eff. 1-1-11. This form is designed for an individual’s initial application for coverage. Please contact the insurer with questions regarding this form.
Instructions: Please complete the entire application for each person for whom coverage is being sought. If a person is currently enrolled in Medicare, this application should not be completed for that enrolled individual. If additional pages are needed to fully complete this application, please attach, sign and date each page.
Primary Applicant/Insured Information:
* If you have a Social Security Number.
* If you have a Social Security Number.
Within the last Five (5) Years:
1. Infectious and Parasitic Diseases
2. Blood, Gland, Endocrine, Metabolic and Immune Disorders (other than HIV, ARC, AIDS)
3. Cancer, Cyst and Tumors
4. Mental/Nervous/Behavioral Disorders
5. Brain and Nervous System
6. Skin Disorders
7. Eyes, Ears, Nose
8. Mouth, Throat or Jaw
9. Heart or Circulatory System
10. Respiratory System
11. Digestive System
12. Urinary System
13. Male or Female Reproductive Systems
14. Pregnancy, Birth or Congenital Abnormalities
15. Muscular or Skeletal System
16. Miscellaneous
17. Other Injury, Illness, Treatment or Condition
18. Tobacco Use
19. Other Activities
ONLY complete this section if you need assistance with completing the medical information portion of this Application. Please note that this may require additional time to process your application.
Signature (or e-signature) of each listed child who has attained the age of 18
Complete this section if someone assisted you in the completion of this Application
Individual Uniform Application Form
OCI 26-503 (c. 06/2010)
Ins 3.34(2)(a)(a) This section applies to disability insurance policies as defined at s. 632.895 (1) (a), Stats., that are issued or renewed on or after January 1, 2010, including individual health and group health benefit plans. It applies to limited–scope plans including vision and dental plans but does not include hospital indemnity, income continuation, accident-only benefits, long-term care and Medigap policies. This section also applies to self-insured health plans as defined at s. 632.745 (24), Stats. Ins 3.34(2)(b)(b) For a disability insurance policy covering employees who are affected by a collective bargaining agreement this coverage under this section first applies as follows: Ins 3.34(2)(b)1.1. If the collective bargaining agreement contains provisions consistent with this law or that are silent on dependent eligibility, coverage under this section first applies the earliest of any of the following; the date the disability insurance policy is issued or renewed on or after January 1, 2010, or the date the self-insured health plan is established, modified, extended or renewed on or after January 1, 2010. Ins 3.34(2)(b)2.2. If the collective bargaining agreement contains provisions inconsistent with this law, the coverage under this section first applies on the date the health policy is first issued or renewed or a self-insured health plan is first established, modified, extended, or renewed on or after the earlier of the date the collectively bargained agreement expires, or the date the collectively bargained agreement it is modified, extended or renewed. Ins 3.34(3)(3) Definitions. In this section and for purposes of applying s. 632.885, Stats.: Ins 3.34(3)(a)(a) “Adult child” means a child of the applicant, enrollee or insured who meets the eligibility requirements of s. 632.885 (2), Stats., as applicable.
