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: __________________
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.
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.
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
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 ________________________
Insurer: ____________________________________________________________
Product Type: _______________________________________________________
Coinsurance Option: _______________ Deductible Option: _______________ Copayment Option: _______________
Selected Provider is for (choose only one): [ ] Health Insurance [ ] Dental Insurance [ ] Other _________________________
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.”
