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