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. Ins 3.34(3)(b)(b) “Premium contribution” means the amount the adult child is required to pay for coverage under the adult child’s employer-sponsored group health benefit plan or self-insured health plan. Ins 3.34(3)(c)(c) “Premium amount” means the additional amount the applicant or insured is required to pay for inclusion of the adult child under the applicant’s or insured’s health insurance policy or self-insured plan. Ins 3.34(4)(4) Premium Determination. To determine whether an adult child meets the eligibility standard in s. 632.885 (2) (a) 3., Stats., the insurer or self-insured health plan must use only the following: Ins 3.34 NoteNote: 2011 Wis. Act 32 repealed s. 632.885 (2) (a) 1. to 3., Stats. See s. 632.885 (2) (a), Stats. Ins 3.34(4)(a)(a) The amount of the adult child’s premium contribution. Ins 3.34(4)(b)(b) The amount of the applicant’s or insured’s premium amount. Ins 3.34(5)(a)(a) On or after January 1, 2010, an insurer and self-insured health plan shall offer coverage to an adult child of an applicant or insured as a new entrant when the applicant or insured requests enrollment of the adult child no later than 30 days after the date the adult child first becomes eligible according to this section. It is solely the applicant’s or insured’s decision whether or not to add eligible adult children to the plan to the extent permitted by law. Ins 3.34(5)(b)(b) Insurers and self-insured health plans may not limit or otherwise restrict the offer of coverage to an eligible adult child by requiring any of the following: Ins 3.34(5)(b)1.1. The eligible adult child to have been previously covered as a dependent. Ins 3.34(5)(b)3.3. The eligible adult child to demonstrate that he or she had previous creditable coverage. Ins 3.34(5)(b)4.4. The insured or applicant to have requested coverage for an eligible adult child the first time the child was eligible for coverage. Ins 3.34(5)(c)(c) Insurers offering individual disability insurance may individually rate the eligible adult child and apply preexisting condition waiting periods consistent with s. 632.76 (2) (ac) 2., Stats., and may apply elimination riders to the eligible adult child, but may not do either of the following: Ins 3.34(5)(c)1.1. Deny coverage to an eligible adult child when the applicant or insured requests coverage. Ins 3.34(5)(c)2.2. Otherwise limit coverage if such limitation results in coverage that is illusory. Ins 3.34(5)(d)(d) Insurers offering group disability insurance policies and self-insured health plans shall comply with all of the following: Ins 3.34(5)(d)1.1. May not deny coverage of an eligible adult child when coverage is requested by the applicant or insured. Ins 3.34(5)(d)2.2. Shall apply portability rights to an eligible adult child so long as the adult child has not had a break in creditable coverage longer than 62 days. Ins 3.34(5)(d)4.4. May request documentation of the adult child’s creditable coverage for determining portability. The pre-existing condition waiting period applicable to the eligible adult child shall be applied to the adult child in the same manner as applied to any other applicant or eligible dependent. Ins 3.34(6)(a)(a) For purposes of this section and implementation of s. 632.885 (2), Stats., an adult child is eligible for coverage as a dependent if either of the following is met: Ins 3.34(6)(a)1.1. For an adult child who has not been called to federal active duty in the national guard or in a reserve component of the U.S. armed forces, either of the following: Ins 3.34 NoteNote: 2011 Wis. Act 32 repealed s. 632.885 (2) (a) 1. to 3., Stats. See s. 632.885 (2) (a), Stats. Ins 3.34(6)(a)1.b.b. An adult child who meets s. 632.885 (2) (a) 1. and 2., Stats., and who is not eligible for his or her employer sponsored coverage or whose employer does not offer health insurance to its employees is an eligible adult child. Ins 3.34 NoteNote: 2011 Wis. Act 32 repealed s. 632.885 (2) (a) 1. to 3., Stats. See s. 632.885 (2) (a), Stats. Ins 3.34(6)(a)2.2. For an adult child who has been called to federal active duty in the national guard or in a reserve component of the U.S. armed forces and who meet s. 632.885 (2) (b) 1., 3., and 4., Stats., all of the following: Ins 3.34(6)(a)2.a.a. The adult child must apply to an institution of higher education as a full-time student within 12 months from the date the adult child has fulfilled his or her active duty obligation. Ins 3.34(6)(a)2.b.b. When an adult child is called to active duty more than once within a four-year period of time, the insurer and self-insured health plan must use the adult child’s age when first called to active duty for determining eligibility under this section. Ins 3.34 HistoryHistory: EmR0930: emerg. cr. eff. 10-31-09; CR 09-076: cr. Register May 2010 No. 653, eff. 6-1-10; corrections in (title) and (6) (a) 1. b. made under s. 13.92 (4) (b) 2. and 7., Stats., Register May 2010 No. 653; correction in (6) (a) 2. made under s. 13.92 (4) (b) 7., Stats., Register March 2017 No. 735. Ins 3.35Ins 3.35 Colorectal cancer screening coverage. Ins 3.35(1)(a)(a) This section applies to disability insurance policies as defined at s. 632.895 (1) (a), Stats., unless otherwise excepted in s. 632.895 (16m) (c), Stats., that are issued or renewed on or after December 1, 2010. This section applies to Medicare supplement and cost plans but does not include limited –scope plans including vision and dental, hospital indemnity, income continuation, accident-only benefits, and long-term care policies. This section also applies to self-insured health plans as defined at s. 632.745 (24), Stats. Ins 3.35(1)(b)(b) For a disability insurance policy and a self-insured health plan covering employees who are affected by a collective bargaining agreement the coverage under this section first applies as follows: Ins 3.35(1)(b)1.1. If the collective bargaining agreement contains provisions consistent with s. 632.895 (16m), Stats., 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 December 1, 2010, or the date the self-insured health plan is established, modified, extended or renewed on or after December 1, 2010. Ins 3.35(1)(b)2.2. If the collective bargaining agreement contains provisions inconsistent with s. 632.895 (16m), Stats., the coverage under this section first applies on the date the health benefit plan 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 is modified, extended, or renewed on or after December 1, 2010. Ins 3.35(2)(2) Definitions. In addition to the definitions contained in s. 632.895 (1), Stats., for purposes of this section all the following apply: Ins 3.35(2)(a)(a) “Designated guideline” means the recommendations of the U.S. Preventive Services Task Force, the National Cancer Institute, or the American Cancer Society regarding colorectal cancer screening guidelines identified by the insurer or self-insured health plan for compliance. Ins 3.35(2)(c)(c) “Self-insured health plan” means a self-insured governmental health plan offered by the state, county, city, village, town, or school district that provides coverage of any diagnostic or surgical procedure. Ins 3.35(3)(3) Colorectal cancer screening guidelines and updates. Ins 3.35(3)(a)(a) Insurers may utilize one or more of the most current colorectal cancer screening guidelines issued by the U.S. Preventive Services Task Force, the National Cancer Institute, or the American Cancer Society as the basis for the coverage offered for preventive colorectal cancer screening tests and procedures. If an insurer or self-insured health plan elects to designate more than one guideline, the insurer or self-insured health plan shall specify the guideline that will be primary in the event of a conflict between the designated guidelines. Insurers shall provide notice of the selected guideline or guidelines and which guideline is primary in a prominent location within the plan summary and in the notice provided to insureds when a benefit is denied based upon the primary guideline. Ins 3.35(3)(b)(b) Insurers and self-insured health plans shall at least annually review the designated guidelines and incorporate modifications to be effective the first day of the subsequent plan year. Ins 3.35(4)(4) Covered screening. Insurers offering disability insurance and self-insured health plans shall offer as a covered benefit the screening for colorectal cancer that may be subject to limitations, exclusions and cost-sharing provisions that generally apply under the plan and comply with all of the following: Ins 3.35(4)(a)(a) Insurers and self-insured health plans shall cover evidence-based, recommended preventive colorectal cancer screening tests or procedures contained in the most current version of the designated guideline. Ins 3.35(4)(b)(b) In accordance with the most current recommendations from the designated guideline for frequency of testing, insurers and self-insured health plans shall provide as a covered benefit, colorectal cancer screening tests or procedures for enrollees who are 50 years of age or older other than as provided for in sub. (5) (b). Medically appropriate or medically necessary covered screening tests or procedures shall at least include 3 of the following: Ins 3.35(4)(c)(c) Insurers and self-insured health plans may require the enrollee’s health care provider or the enrollee’s primary care provider to obtain prior authorization for screening tests or procedures when the screening test or procedure is not contained in the most current version of guideline recommendations designated by the insurer or self-insured health plan. Ins 3.35(4)(d)(d) Disputes regarding coverage of medically appropriate or medically necessary evidence-based screening tests or procedures are subject to internal grievance and independent review as provided by ch. Ins 18. Ins 3.35(5)(a)(a) In accordance with recommended factors for identifying persons at high risk for colorectal cancer developed by the American Cancer Society, insurers and self-insured health plans shall provide as a covered benefit evidence-based colorectal cancer screening tests and procedures at recommended ages and intervals for enrollees determined to be at high risk for developing colorectal cancer. Insurers and self-insured health plans that designated either the U.S. Preventive Services Task Force or the National Cancer Institute as the designated guideline may include additional high risk factors when the guidelines identify factors for persons at high risk for colorectal cancer. All insurers and self-insured health plans shall at a minimum consider all of the following factors, as appropriate, when determining whether an enrollee is at high risk for colorectal cancer:
