If you need to complete this section for more than one person, please use a separate sheet of paper and attach it to this application (please sign and date the additional sheet).
Are you, your spouse or your child(ren) covered by Medicare Part A? [ ] Yes [ ] No Medicare Part B? [ ] Yes [ ] No
Medicare Part D [ ] Yes [ ] No
Name of person covered by Medicare: ____________________________________
If “Yes,” reason for Medicare: [ ] Over Age 65 [ ] Disability [ ] End-Stage Renal Disease (ESRD) [ ] Disability and ESRD
Medicare Part A Effective Date: _________________ Medicare Part B Effective Date ___________________
Medicare Part C (Medicare Advantage) Effective Date: _________________ Medicare Part D Effective Date: __________________
The information you provide about your other individual or group health insurance coverage (either prior or current) is necessary to determine whether you will have any waiting periods for preexisting conditions under the group health insurance plan under which you are applying for coverage. Your information will also help the small employer insurer(s) to coordinate benefits with any other group health coverage you may have. By providing this information you are not reducing your group health insurance for which you are applying.
If “Yes,” please complete the following table and attach a copy of the Certificates of Creditable Coverage for each person.
Starting with you, the employee, identify each person applying for insurance and include information for all current and previous health insurance coverage(s) in effect during the last 18 months.
Type of Coverage Key: G = Group Comprehensive Major Medical; I = Individual Comprehensive Major Medical;
M = Medicare Supplement; D = Drug Coverage Only; H = Hospital Coverage Only; V = Vision Coverage Only
This section should be completed only if the small employer group insurance for which you are applying requires the selection of a network, primary care provider or clinic. If applicable, it should also be used to select the product options offered by the employer or insurer. With respect to the provider or network selection, a selection should be made for each individual applying for such coverage and for each insurer from which insurance coverage is being sought. The provider numbers may be listed in the provider materials (i.e., directory) that are supplied by each insurer to your employer. The provider numbers for the same provider may not be the same for different insurers or products. Use additional sheets if necessary.
Insurer: ____________________________________________________________
Product Type: _______________________________________________________
Coinsurance Option: _______________ Deductible Option: _______________ Copayment Option: _______________
Selected Provider is for (choose only one): [ ] Health Insurance [ ] Dental Insurance [ ] Other ________________________
Insurer: ____________________________________________________________
Product Type: _______________________________________________________
Coinsurance Option: _______________ Deductible Option: _______________ Copayment Option: _______________
Selected Provider is for (choose only one): [ ] Health Insurance [ ] Dental Insurance [ ] Other _________________________
Availability of coverage is determined by your employer and whether the coverage is approved for issuance by the insurer(s).
Please list the insurer(s) below from whom you are applying for coverage and check all benefits for which you are applying.
If you have been given a choice of plans to apply for, or if the coverage you are applying for requires the selection of a primary care provider/clinic/network, please complete the section entitled “Provider and/or Product Selection.”
If you are waiving application for any coverage on yourself and/or your spouse and/or dependent child(ren), please complete the “Waiver of Coverage” section at the end of this section.
[ ] Employee [ ] Employee and Spouse [ ] Employee and Dependent Child(ren)
[ ] Employee, Spouse and Dependent Child(ren)
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
Within the past 12 months, have you, your spouse or your dependent child(ren) had any individual or other group dental coverage? [ ] Yes [ ] No
If “Yes,” please provide the following information:
Orthodontia coverage? [ ] Yes [ ] No
Dental Insurer Name: _______________________________ Policy Number: ____________________
Address: __________________________________________ Phone Number: ____________________
Coverage Effective Date: __________________ Termination Date: ____________________
Is coverage still in effect? [ ] Yes [ ] No
Who was or is covered under the policy listed above? _____________________________________________________
Please attach copies of Certificates of Prior Coverage.
Insurer: __________________________________________ Insurer: __________________________________________
Insurer: __________________________________________ Insurer: __________________________________________
Employee Life/AD&D Amounts: Basic Issue $__________ Supplemental $__________ Optional $__________
Primary Beneficiary Name ________________________________ Beneficiary’s Social Security ___________________
Relationship of Beneficiary _____________________
Secondary Beneficiary Name ______________________________ Beneficiary’s Social Security ___________________
Relationship of Beneficiary _____________________
Dependent Life Amounts: Basic Issue $__________ Supplemental $__________ Optional $__________
[ ] Dependent Spouse Only [ ] Dependent Child(ren) Only [ ] Dependent Spouse and Dependent Child(ren)
[ ] Short Term Disability [ ] Long Term Disability Your Annual Salary $__________________
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
Basic Benefit Amount $______________/ per week Optional Benefit Amount $_____________/ per week
[ ] Employee [ ] Employee and Spouse [ ] Employee and Dependent Child(ren)
[ ] Employee, Spouse and Dependent Child(ren)
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
[ ] Employee [ ] Employee and Spouse [ ] Employee and Dependent Child(ren)
[ ] Employee, Spouse and Dependent Child(ren)
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
I understand that I am eligible to apply for coverage through my employer. I do NOT want coverage for (check all that apply):
Employee: [ ] Dental [ ] Basic Life/AD&D [ ] Supplemental Life/AD&D [ ] Optional Life
[ ] Basic Disability [ ] Optional Disability [ ] Drug [ ] Vision
Spouse: [ ] Dental [ ] Basic Life [ ] Supplemental Life [ ] Optional Life [ ] Drug [ ] Vision
Dependent Child(ren): [ ] Dental [ ] Basic Life [ ] Supplemental Life [ ] Optional Life [ ] Drug [ ] Vision
The reason I am waiving group coverage at this time is because of:
[ ] Spousal coverage [ ] Individual Coverage [ ] Medicare [ ] Medical Assistance
[ ] Other: _____________________________________________________________________
WAIVER: I certify that I was not pressured, forced or unfairly induced by my employer, the agent, or the insurer(s) into waiving (declining) the above-noted coverage. I understand that in the event that I should decide to apply for such coverage at a later date, the application will be subject to the applicable terms and conditions of the employer’s policy(s), which may require additional limitations and waiting periods. I also understand that I, my spouse and my dependent child(ren) may be required to furnish, at my own expense, evidence of health status/health history representation satisfactory to the insurer(s). I understand that the insurer(s) reserves the right to deny coverage with any future application for coverage.
Signature of Employee: ______________________________________ Date Signed: __________________
Signature of Spouse: _________________________________________ Date Signed: __________________
I hereby enroll for coverage under the insurance coverage(s) for which I am presently eligible, or for which I may become eligible under my employer’s group contract(s). I have indicated in this Wisconsin Uniform Employee Application for Small Employer Group Health Insurance, if required, the Provider or Product Selection. I understand and agree that the information obtained by using this Application will be used by the insurer(s) to determine eligibility for benefits under my employer’s group insurance policies. I, on behalf of myself, my spouse and my dependent child(ren), if any, named herein, agree to cooperate in providing the insurer(s) with information needed to process this Application. This might include signing a form for the release by hospitals, doctors, and other health care providers of pertinent health care records to the Medical Information Bureau, the insurer(s) or their legal representatives.
I acknowledge that I have read and completed the entire Application. If I received assistance in reading or completing this Application, I have identified in the space provided below the person(s) who provided me with such assistance. I declare and agree that the answers are, to the best of my knowledge and belief, complete and true and, together with any supplements or addendums thereto, shall be the basis for any certificate of coverage or certificate of insurance issued. I understand and agree that neither the employer nor the agent has the authority to waive a complete answer to any question, pass on insurability, alter any contract, or waive any of the insurer’s other rights or requirements. I additionally agree that the insurer(s) is not liable for any statement, representation, or other information provided to me, my spouse or my dependent child(ren) that is not expressly contained in a written document provided by the insurer and signed by an authorized officer of the insurer. I agree that no insurance will be effective until the date specified by the company on the certificate of coverage or certificate of insurance after this application has been accepted. I understand that any misrepresentation contained herein and relied upon by the insurer may be used to reduce or deny a claim or void the contract within the contestable period if such misrepresentation materially affects the acceptance of risk. I also understand that if I decline any coverage, future changes in coverage are NOT automatic and may be subject to the insurer’s approval.
I understand and acknowledge that any person who, with intent to defraud or knowledge that the person is facilitating a fraud against an insurer, submits an application or files a claim containing a false deceptive statement is committing a fraudulent act that is a crime. I further understand and acknowledge that in some states, any person who, for the purpose of intentionally misleading an insurer or other person, conceals significant information from an application or claim is committing a fraudulent act.
If any payroll deductions are required for this coverage, I authorize such deductions from my earnings. I reserve the right to revoke this deduction authorization at any time upon written notice to the employer. An Application should not be submitted more than 45 days prior to the effective date. This document will become a part of the insurance contract when coverage is approved and issued.
I understand that I may request a copy of this Application and the Authorization to Use and Disclose Protected Health Information that are part of this Application. I agree that a photographic copy shall be as valid as the original. A legible facsimile signature shall have the same force and effectiveness as the original.
Signature of Employee: ___________________________________________ Date Signed: __________________
