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:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
-
See PDF for table 
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):
-
See PDF for table -
See PDF for table
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.)
- See PDF for table
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.)
- See PDF for table - See PDF for table
I understand that I am eligible to apply for group health insurance through my employer. I do NOT want, and hereby waive, group health insurance for (check the box that applies):
[ ] Waiving for myself [ ] Waiving for my spouse [ ] Waiving for my dependent child(ren)
[ ] Waiving for me, my spouse and my dependent child(ren)
I am waiving group health insurance because (check all that apply):
[ ] I, the employee, am covered or will be covered under another plan that is not sponsored by my employer. I am not enrolled for coverage under the Health Insurance Risk-Sharing Plan (HIRSP). If currently covered, please attach a copy of your identification card for that plan.
[ ] I, the employee, do not have a risk characteristic or other attribute that would be the sole cause for the small employer insurer to make a decision with respect to premiums or eligibility for a policy that is adverse to the small employer.
[ ] My spouse is covered or will be covered under another plan that is not sponsored by this employer. My spouse is not enrolled for coverage under the Health Insurance Risk-Sharing Plan (HIRSP). If currently covered, please attach a copy of your spouse's identification card for that plan.
[ ] My dependent child(ren) is covered or will be covered under another plan that is not sponsored by my employer. My dependent child(ren) is not enrolled for coverage under the Health Insurance Risk Sharing Plan (HIRSP). If currently covered, please attach your identification card for that plan. Please list, below, the name(s) of the child(ren) for whom coverage is being waived.
[ ] I am not enrolled under the Health Insurance Risk-Sharing Plan (HIRSP) and the annualized premium contribution to be paid by me on behalf of myself or my dependent spouse and child(ren) would exceed 10% of my annualized gross earnings from this employer.
[ ] Other reason (Please provide a written reason for waiving coverage):
____________________________________________________________________________________________________
WAIVER: I certify that I have been given the opportunity to apply for group health insurance and decline to enroll as indicated above, on behalf of myself, my spouse and my dependent child(ren). I understand that by signing this waiver, I, my spouse, and my dependent child(ren) forfeit the right to coverage. I was not pressured, forced or unfairly induced by my employer, the agent or the insurer(s) into waiving or declining the group health insurance. If in the future I apply for coverage, I, my spouse, or any of my dependent child(ren) may be treated as a late enrollee and subject to postponement or an exclusion of coverage for preexisting conditions for a period of up to 18 months. This period may be offset by the time I, my spouse or my dependent child(ren) was covered under a qualified health plan.
I understand that if I am declining enrollment for myself, my spouse, or my dependent child(ren) because of other health insurance coverage, including Medicaid, I may in the future be able to enroll myself, my spouse, or my dependent child(ren) in this plan, provided that I request enrollment within 30 days after my other health coverage ends or 60 days after Medicaid ends. In addition, if I gain a dependent spouse or child(ren) as a result of marriage, birth, adoption, or placement for adoption, I understand that I may be able to enroll myself, my spouse and my dependent child(ren), provided that I request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. If I am declining enrollment for myself, my spouse or my dependent child(ren) because of coverage under Medicaid, I understand that if I, my spouse or my dependent child(ren) become eligible for group health plan premium assistance under Medicaid, I may be able to enroll myself, my spouse or my dependent child(ren), provided I request enrollment within 60 days of initial eligibility for the premium assistance. I understand that I can obtain enrollment information from my employer or small employer group health insurance carrier.
Signature of Employee: ______________________________________________ Date Signed: ____________________________
-
See PDF for table
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: __________________
-
See PDF for table
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.
-
See PDF for table
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.
-
See PDF for table
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
-
See PDF for table
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 ________________________
-
See PDF for table
Insurer: ____________________________________________________________
Product Type: _______________________________________________________
Coinsurance Option: _______________ Deductible Option: _______________ Copayment Option: _______________
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.
-
See PDF for table
[ ] 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? _____________________________________________________
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)
-
See PDF for table
[ ] Short Term Disability [ ] Long Term Disability Your Annual Salary $__________________
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
Basic Benefit Amount $______________/ per week
Optional Benefit Amount $_____________/ per week
-
See PDF for table
[ ] Employee [ ] Employee and Spouse [ ] Employee and Dependent Child(ren)
[ ] Employee, Spouse and Dependent Child(ren)
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
-
See PDF for table
[ ] Employee [ ] Employee and Spouse [ ] Employee and Dependent Child(ren)
[ ] Employee, Spouse and Dependent Child(ren)
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
-
See PDF for table
