[ ] 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: __________________
Signature of Spouse: _____________________________________________ Date Signed: __________________
Signature of each listed dependent who has attained the age of 18:
________________________________________ Date Signed: ___________ Print Name _______________________
________________________________________ Date Signed: ___________ Print Name _______________________
Complete this section if someone assisted you in the completion of this Application.
The following person assisted me in completing the Application: ____________________________________________
Please explain your relationship with the Applicant: ______________________________________________________
Instructions: Please read this authorization form carefully before signing. This form must be signed by each adult person seeking coverage, including all adult dependent children. Parents should sign for their minor children unless the minor has received treatment without parental consent, consistent with state law. Your application cannot be processed without a signature for each person seeking coverage. Signing this form is a condition of coverage: if you decide not to sign, you will not be enrolled in a health plan of the insurers listed below. You have the right to receive a copy of this form following your signature.
I. Protected Health Information
By signing this form, I authorize certain organizations and persons to use or disclose my, my spouse’s and my dependent child(ren)’s protected health information. Protected health information includes, but is not limited to, hospital records, physician records, lab results, mental health records, and alcohol and/or drug abuse records. Protected health information may be written, oral, or electronic. This form does not permit the use or disclosure of psychotherapy notes or the disclosure of information concerning whether I, my spouse or my dependent child(ren) have obtained a test for the presence of HIV antigen or nonantigenic products of HIV or an antibody to HIV or what the results of this test were.
II. Purpose of this Authorization Form
By signing this form, I, my spouse and my dependent child(ren) authorize the use and disclosure of protected health information for the purposes of pre-enrollment underwriting or risk-rating of health insurance coverage for me, my spouse and my dependent child(ren), to determine eligibility for enrollment or benefits under a health plan or to allow the insurer to conduct utilization review and quality improvement activities (“Purpose”).
III. Entities Authorized to Use and Disclose My Protected Health Information
Insurers: I hereby authorize the following insurers, their reinsurers, and their legal representatives (“Insurers”) to receive, use, and disclose my, my spouse’s and my dependent child(ren)’s protected health information for the Purpose listed above:
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
I authorize the Insurers to disclose my, my spouse’s and my dependent child(ren)’s protected health information: between themselves, to reinsuring companies, and to the plan administrator (if other than the employer), plan sponsor (if other than the employer), insurance intermediaries, or other persons or organizations performing business or legal services in connection with the Purpose above.
I further authorize any licensed physician, medical practitioner, health care provider, hospital, clinic, or other medical or medically related facility, insurance or reinsuring company, Medical Information Bureau, Inc., consumer reporting agency, or other organization, institution, or person that has any record or knowledge of me, my spouse or my dependent(s), to give to Insurers any and all protected health information about me, my spouse, or my dependent(s) to be covered concerning diagnosis, treatment and prognosis for any physical or mental condition, history or character, general reputation, personal trait, and mode of living, including, but not limited to, all medical and health care records, but not including whether I, my spouse or my dependent(s) obtained a test for the presence of HIV antigen or nonantigenic products of HIV or what the results of this test were.
I, my spouse and my dependent child(ren) understand that protected health information described in this form may be used by, or disclosed to or by, organizations and persons who are not subject to federal or state privacy laws.
IV. Term of Authorization
I agree this Authorization shall be valid for two and one half (2 ½) years from the latest signature date below.
V. Right to Revoke
I understand I, my spouse or my dependent child(ren) may revoke this authorization at any time by giving advance written notice to Insurers. Revocation of this authorization form will not affect actions Insurers and others took in reliance on this form prior to the written notice of revocation.
I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THIS FORM. I UNDERSTAND THAT, BY SIGNING THIS FORM, I AUTHORIZE THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION DESCRIBED IN THIS FORM. I UNDERSTAND THAT I MAY ONLY REVOKE AUTHORIZATION FOR MYSELF OR MY MINOR CHILD(REN) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW. (CONTINUED ON THE NEXT PAGE.)
_________________________________ ________________ _________________________________
Signature of Adult Applicant Date signed Printed Name
_________________________________ ________________ _________________________________
Signature of Spouse (if applicable) Date signed Printed Name
I have had full opportunity to read and consider this form. I understand that, by signing this form, I authorize the uses and disclosures of protected health information described in this form. I understand that I may only revoke authorization for myself or my minor child(ren) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW.
___________________________________ ________________ _________________________________
Signature of Adult Dependent Date signed Printed Name
___________________________________ ________________ _________________________________
Signature of Parent or Legal Guardian Date signed Name of Minor Child (please print)
for Minor Child(ren) (if applicable)
If signing for more than one child, please list the names of each child for whom you are signing:
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
For services received by a minor that under state law the minor may consent to treatment without parental or legal guardian consent:
