Ins 8.46(2)(c)(c) For a small employer with 8 or 9 eligible employees, 5 eligible employees. Ins 8.46(2)(d)(d) For a small employer with 7 eligible employees, 4 eligible employees. Ins 8.46(2)(e)(e) For a small employer with 5 or 6 eligible employees, 3 eligible employees. Ins 8.46(2)(f)(f) For a small employer with 2 to 4 eligible employees, 2 eligible employees. Ins 8.46 HistoryHistory: Cr. Register, October, 1992, No. 442, eff. 11-1-92; am. (2), Register, November, 1993, No. 455, eff. 2-1-94. Ins 8.48Ins 8.48 Solicitation; disclosure requirements. Ins 8.48(1)(1) Agents. Before completing an application for a policy, an agent shall provide the small employer or representative of the small employer or the individual applicant with a form stating the information required under s. 635.11 (1m), Stats. The agent shall sign and date the form certifying that he or she made the required disclosure and shall obtain the signature of the small employer or representative of the small employer or the individual applicant on the form. The agent shall give one copy of the completed form to the person who signed it. The agent or small employer insurer shall retain one copy of the completed form. Ins 8.48(2)(2) Small employer insurers. A small employer insurer that does not use agents to solicit or sell policies shall, with any solicitation material, provide the small employer or individual applicant with a form stating the information required under s. 635.11 (1m), Stats. The small employer insurer shall secure with or as part of each application a form signed by the small employer, a representative of the small employer or individual applicant stating that he or she has received the information. The small employer insurer shall provide a copy to the person who signed the form no later than the date the policy is issued. Ins 8.48 HistoryHistory: Cr. Register, October, 1992, No. 442, eff. 11-1-92; corrections made under s. 13.93 (2m) (b) 7., Stats., Register October 2002 No. 562. Ins 8.49Ins 8.49 Uniform employee application form. Ins 8.49(1)(a)(a) In accordance with s. 635.10, Stats., small employer insurers shall use the small employer uniform employee application form as the only acceptable form when small employers apply for coverage from small employer insurers. Small employer insurers shall implement procedures and policies necessary to use the small employer uniform employee application form. Ins 8.49(1)(b)(b) Small employer insurers shall treat and accept a copy of the uniform employee application as an original. Ins 8.49(1)(c)(c) The contents of the uniform small employer application shall not vary, except as permitted in par. (d), from the text or format including bold character, line spacing, the use of boxes around text and shall use a type size of at least 10 points as delineated in form OCI 26-501. Ins 8.49(1)(d)(d) Small employer insurers and licensed intermediaries may pre-print the name of the small employer insurer on the uniform employee application provided that the form contains at least 3 additional spaces to insert the names of insurers to whom the uniform applications may be sent and the form complies with par. (c). Ins 8.49 NoteNote: A copy of the uniform employee application form OCI 26-501 (c. 2/2004), required in par. (a), may be obtained at no cost from the Office of the Commissioner of Insurance, P.O. Box 7873, Madison WI 53707-7873, or at the Office’s web address: oci.wi.gov.
Ins 8.49(2)(a)(a) The information contained within each uniform employee application shall be considered current information by the small employer insurer if the information is received by the small employer insurer within 45 days of completion of the earliest signed and completed uniform employee application form. For the period of time that the information contained within the uniform employee application is considered current, small employer insurers may not require a small employer employee to complete a new application form or any document, addendum or certification representing that the information contained in the completed uniform employee applications is current. Ins 8.49(2)(b)(b) A small employer insurer may accept and utilize information provided by a small employer employee subsequent to the date the employee signed the completed application if the employee is providing the insurer with additional or modified information. Ins 8.49(2)(c)(c) A small employer insurer may require small employer employees to complete and submit new uniform employee applications if either of the following occurs: Ins 8.49(2)(c)1.1. The authorization signed by the employees does not include the name of the small employer insurer that the small employer is requesting provide it with an underwritten premium amount and coverage. Ins 8.49(2)(c)2.2. The completed uniform employee applications are received by the small employer insurer after 45 days of completion of the earliest signed and completed uniform employee application. Ins 8.49(3)(a)(a) Small employer insurers that receive a written request from a small employer to forward copies of the completed uniform employee applications to a different small employer insurer listed within the authorization section of the application shall forward copies of the uniform employee applications within 5 business days from receipt of the request without requiring a fee be paid for the photocopying or delivery of the copies of completed uniform employee applications. The small employer insurer shall notify the employer, as soon as practicable, if the small employer insurer is unable to comply with the request because the small employer has requested that information be sent to a small employer insurer not identified within the authorization. Ins 8.49(3)(b)(b) An intermediary shall forward, within 5 business days from receipt of the applications, copies of the uniform employee applications to all small employer insurers identified within the uniform employee application authorization to receive the applications, or to an authorized representative of each small employer insurer. The intermediary may withhold distribution to a small employer insurer, or the insurer’s authorized representative, at the request of the small employer. Ins 8.49(3)(c)(c) Completed uniform employee applications shall be maintained by small employer insurers and licensed intermediaries, as applicable, in accordance with subch. V of ch. Ins 25. Ins 8.49(4)(a)(a) Small employer insurers shall either state the premium to the small employer within 10 business days from receipt of all pertinent information required for its underwriting of the small employer’s application for group health insurance, including completed uniform employee applications, or deny the application in accordance with s. 635.18 (6), Stats. Ins 8.49(4)(b)(b) Small employer insurers shall make a reasonable effort to promptly obtain information it determines is necessary to make an underwriting decision including the information described in par. (a). Ins 8.49 HistoryHistory: CR 03-055: cr. Register April 2004 No. 580, eff. 5-1-04. APPENDIX 1
Employee Name_______________________
This form is designed for an employer’s initial application for coverage. Please contact your agent or the insurer to determine if this form should be used in other situations once the group is enrolled with the insurer.
Employer Name _________________________________ Group Number ______________ Division Number ____________
Employee Class _________________
Total number of permanent employees who have a normal work week of 30 or more hours _________
Names of Insurers to whom information may be released:
Insurer: __________________________________________ Insurer: _____________________________________________
Insurer: __________________________________________ Insurer: _____________________________________________
Employee Instructions: Please print using black or blue ink. Please fill out the entire application for each person for whom coverage is being sought.
Employee’s First Name, Middle Initial and Last Name: ___________________________________________________________
Social Security No.: __________________ Birth Date: _________________ Sex: _______ Height and Weight:_____________
Street or Post Office Address: ______________________________________________________________________________
City: _______________________________ County:____________________ State: ___________________Zip: ____________
Home Phone: __________________Work Phone: _________________ Email: _____________________ [ ] Home [ ] Work
1. For your current employer: What was your first day of employment? ____/____/____
How many hours, on average, do you work each week? ______
2. Are You:
a) [ ] Single [ ] Married [ ] Legally Separated [ ] Divorced [ ] Widow or Widower
If you are married, legally separated, divorced or widowed, please indicate the date that the event occurred: __________
If you are married, please indicate the county and state, or country in which you were married: _____________________
If you are married, please indicate your former or maiden name: __________________________________
b) A Retiree? [ ] Yes [ ] No
c) On COBRA or State Continuation? [ ] Yes [ ] No
If “Yes,” provide start date and reason: _________________________________________________________________
Please select the type of health insurance coverage for which you are applying:
[ ] Employee Only [ ] Employee and Spouse [ ] Employee and Dependent Child(ren) [ ] Employee, Spouse and Dependent Child(ren)
a) List all dependents, spouse and child(ren) applying for insurance. If you need additional space, please use a separate sheet of paper and attach it to this application (please sign and date the additional sheet).
b) Does the dependent child(ren) named within this application live with you at the address shown above? [ ] Yes [ ] No
If “No,” please list the dependent child(ren)’s name and address(es):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
c) If there is a stipulation in a legal decree or court order stating who is responsible for providing health insurance of the named dependent child(ren), please indicate name of the person who has primary custody of the dependent child(ren) and the name of the responsible person for health insurance:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Please answer the following questions to the best of your knowledge. On the next page, please provide the complete details if you answer “Yes” to any of the questions below. The date that this application is signed is the date that you should use when answering questions that request you to provide prior history for various periods of time. The health insurance company does not use or collect genetic information for any underwriting purpose. Genetic information includes information related to genetic tests, genetic counseling, and any family history of a disease or disorder. Any such information should not be included on an application or communicated to the insurance company in any manner. Any genetic information that may be obtained will not be used for underwriting of health coverage. You are required to promptly notify your employer so that you may provide updated information to the small employer insurer(s) of any changes or developments in your, your spouse’s or your dependent child(ren)’s health history that occur prior to your employer’s notifying you that there has been an insurer’s underwriting decision regarding this application.
A. Are you, your spouse or any dependent child(ren) (even if not listed on the application) currently pregnant or an expectant parent? (If “Yes,” due date is __________________) [ ] Yes [ ] No
B. Has anyone named in this application been treated or diagnosed by a medical professional as having Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)? [ ] Yes [ ] No
C. Has anyone named in this application used tobacco or smokeless tobacco during the past 12 months? [ ] Yes [ ] No
If “Yes,” provide information as requested regarding the product, duration and frequency of use in section H below.
D. In the past 5 years has anyone named in this application been evaluated or treated for alcoholism or chemical dependency; or joined any organization for alcoholism or chemical dependency; or used illegal drugs or been advised by a health care professional to reduce the use of alcohol or illegal drugs? [ ] Yes [ ] No
E. Is anyone named in this application now disabled, mentally incompetent or unable to perform normal work or age-related activities? [ ] Yes [ ] No
If “Yes,” please identify name(s), health condition(s), date(s) of disability and name(s) and address(es) of the attending physician(s):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
F. Within the past 10 years, has anyone named in this application been counseled, consulted or treated for any of the following (please check all conditions that apply):
G. Within the last 5 years, has anyone named in this application to be covered by this insurance had any other injury, illness or treatment for any condition not already listed; been hospitalized or been scheduled for hospitalization; had surgery or had surgery scheduled; had a test or a test scheduled; or been recommended to have a test or surgery which was not performed for any reason not already mentioned in this application? We are not seeking the results of HIV Antibody test. [ ] Yes [ ] No
H. In the space below please list and provide the complete details if you answered “Yes” above to any of the questions or conditions contained in sections A through F. (Attach additional pages as needed and sign the additional pages.)
I. If anyone named in this application is taking medication or has had prescribed or recommended any medication during the period of time related to your answer (i.e. past 5 years, past 10 years, or currently taking), please list all those medications, dosages, and what medical condition is being treated or were treated by each medication in the space provided below. (Attach additional pages as needed and sign the additional pages.)
