Section 8.49. Uniform employee application form.

 

(1)  

(a) In accordance with s. 635.10 , Stats., small employer insurers shall use the small employer uniform employee application form as the only acceptable form when small employers apply for coverage from small employer insurers. Small employer insurers shall implement procedures and policies necessary to use the small employer uniform employee application form.

(b) Small employer insurers shall treat and accept a copy of the uniform employee application as an original.

(c) The contents of the uniform small employer application shall not vary, except as permitted in par. (d) , from the text or format including bold character, line spacing, the use of boxes around text and shall use a type size of at least 10 points as delineated in form OCI 26-501.

(d) Small employer insurers and licensed intermediaries may pre-print the name of the small employer insurer on the uniform employee application provided that the form contains at least 3 additional spaces to insert the names of insurers to whom the uniform applications may be sent and the form complies with par. (c) .

(2)  

(a) The information contained within each uniform employee application shall be considered current information by the small employer insurer if the information is received by the small employer insurer within 45 days of completion of the earliest signed and completed uniform employee application form. For the period of time that the information contained within the uniform employee application is considered current, small employer insurers may not require a small employer employee to complete a new application form or any document, addendum or certification representing that the information contained in the completed uniform employee applications is current.

(b) A small employer insurer may accept and utilize information provided by a small employer employee subsequent to the date the employee signed the completed application if the employee is providing the insurer with additional or modified information.

(c) A small employer insurer may require small employer employees to complete and submit new uniform employee applications if either of the following occurs:

1. The authorization signed by the employees does not include the name of the small employer insurer that the small employer is requesting provide it with an underwritten premium amount and coverage.

2. The completed uniform employee applications are received by the small employer insurer after 45 days of completion of the earliest signed and completed uniform employee application.

(3)  

(a) Small employer insurers that receive a written request from a small employer to forward copies of the completed uniform employee applications to a different small employer insurer listed within the authorization section of the application shall forward copies of the uniform employee applications within 5 business days from receipt of the request without requiring a fee be paid for the photocopying or delivery of the copies of completed uniform employee applications. The small employer insurer shall notify the employer, as soon as practicable, if the small employer insurer is unable to comply with the request because the small employer has requested that information be sent to a small employer insurer not identified within the authorization.

(b) An intermediary shall forward, within 5 business days from receipt of the applications, copies of the uniform employee applications to all small employer insurers identified within the uniform employee application authorization to receive the applications, or to an authorized representative of each small employer insurer. The intermediary may withhold distribution to a small employer insurer, or the insurer's authorized representative, at the request of the small employer.

(c) Completed uniform employee applications shall be maintained by small employer insurers and licensed intermediaries, as applicable, in accordance with subch. V of ch. Ins 25 .

(4)  

(a) Small employer insurers shall either state the premium to the small employer within 10 business days from receipt of all pertinent information required for its underwriting of the small employer's application for group health insurance, including completed uniform employee applications, or deny the application in accordance with s. 635.18 (6) , Stats.

(b) Small employer insurers shall make a reasonable effort to promptly obtain information it determines is necessary to make an underwriting decision including the information described in par. (a) .

History: CR 03-055 : cr. Register April 2004 No. 580 , eff. 5-1-04.

Note

A copy of the uniform employee application form OCI 26-501 (c. 2/2004), required in par. (a), may be obtained at no cost from the Office of the Commissioner of Insurance, P.O. Box 7873, Madison WI 53707-7873, or at the Office's web address: oci.wi.gov. Microsoft Windows NT 6.1.7601 Service Pack 1 APPENDIX 1 Microsoft Windows NT 6.1.7601 Service Pack 1 Employee Name_______________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 This form is designed for an employer's initial application for coverage. Please contact your agent or the insurer to determine if this form should be used in other situations once the group is enrolled with the insurer. - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 Employer Name _________________________________ Group Number ______________ Division Number ____________ Microsoft Windows NT 6.1.7601 Service Pack 1 Employee Class _________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Total number of permanent employees who have a normal work week of 30 or more hours _________ Microsoft Windows NT 6.1.7601 Service Pack 1 Names of Insurers to whom information may be released: Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: __________________________________________ Insurer: _____________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: __________________________________________ Insurer: _____________________________________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 Employee Instructions: Please print using black or blue ink. Please fill out the entire application for each person for whom coverage is being sought. Microsoft Windows NT 6.1.7601 Service Pack 1 Employee's First Name, Middle Initial and Last Name: ___________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Social Security No.: __________________ Birth Date: _________________ Sex: _______ Height and Weight:_____________ Microsoft Windows NT 6.1.7601 Service Pack 1 Street or Post Office Address: ______________________________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 City: _______________________________ County:____________________ State: ___________________Zip: ____________ Microsoft Windows NT 6.1.7601 Service Pack 1 Home Phone: __________________Work Phone: _________________ Email: _____________________ [ ] Home [ ] Work Microsoft Windows NT 6.1.7601 Service Pack 1 1.   For your current employer: What was your first day of employment? ____/____/____ Microsoft Windows NT 6.1.7601 Service Pack 1   How many hours, on average, do you work each week? ______ Microsoft Windows NT 6.1.7601 Service Pack 1 2.   Are You: Microsoft Windows NT 6.1.7601 Service Pack 1   a)   [ ] Single   [ ] Married   [ ] Legally Separated   [ ] Divorced   [ ] Widow or Widower Microsoft Windows NT 6.1.7601 Service Pack 1     If you are married, legally separated, divorced or widowed, please indicate the date that the event occurred: __________ Microsoft Windows NT 6.1.7601 Service Pack 1     I f you are married, please indicate the county and state, or country in which you were married: _____________________ Microsoft Windows NT 6.1.7601 Service Pack 1     If you are married, please indicate your former or maiden name: __________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1   b)   A Retiree? [ ] Yes [ ] No Microsoft Windows NT 6.1.7601 Service Pack 1   c)   On COBRA or State Continuation? [ ] Yes [ ] No Microsoft Windows NT 6.1.7601 Service Pack 1     If "Yes," provide start date and reason: _________________________________________________________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 Please select the type of health insurance coverage for which you are applying: Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Employee Only [ ] Employee and Spouse [ ] Employee and Dependent Child(ren) [ ] Employee, Spouse and Dependent Child(ren) - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 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) . - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 b) Does the dependent child(ren) named within this application live with you at the address shown above? [ ] Yes [ ] No Microsoft Windows NT 6.1.7601 Service Pack 1 If "No," please list the dependent child(ren)'s name and address(es): Microsoft Windows NT 6.1.7601 Service Pack 1 ______________________________________________________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 ______________________________________________________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 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: Microsoft Windows NT 6.1.7601 Service Pack 1 ______________________________________________________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 ______________________________________________________________________________________________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 C. Has anyone named in this application used tobacco or smokeless tobacco during the past 12 months?   [ ] Yes [ ] No Microsoft Windows NT 6.1.7601 Service Pack 1   If "Yes," provide information as requested regarding the product, duration and frequency of use in section H below. Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 E. Is anyone named in this application now disabled, mentally incompetent or unable to perform normal work or age-related activities?   [ ] Yes [ ] No Microsoft Windows NT 6.1.7601 Service Pack 1 If "Yes," please identify name(s), health condition(s), date(s) of disability and name(s) and address(es) of the attending physician(s): Microsoft Windows NT 6.1.7601 Service Pack 1 ______________________________________________________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 ______________________________________________________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 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): Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Waiving for myself   [ ] Waiving for my spouse   [ ] Waiving for my dependent child(ren) Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Waiving for me, my spouse and my dependent child(ren) Microsoft Windows NT 6.1.7601 Service Pack 1 I am waiving group health insurance because (check all that apply) : Microsoft Windows NT 6.1.7601 Service Pack 1 [ ]   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. Microsoft Windows NT 6.1.7601 Service Pack 1 [ ]   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. Microsoft Windows NT 6.1.7601 Service Pack 1 [ ]   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. Microsoft Windows NT 6.1.7601 Service Pack 1 [ ]   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. Microsoft Windows NT 6.1.7601 Service Pack 1 [ ]   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 . Microsoft Windows NT 6.1.7601 Service Pack 1 [ ]   Other reason (Please provide a written reason for waiving coverage): Microsoft Windows NT 6.1.7601 Service Pack 1 ____________________________________________________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Employee: ______________________________________________ Date Signed: ____________________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 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) . Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 Name of person covered by Medicare: ____________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 If "Yes," reason for Medicare: [ ] Over Age 65 [ ] Disability [ ] End-Stage Renal Disease (ESRD) [ ] Disability and ESRD Microsoft Windows NT 6.1.7601 Service Pack 1 Medicare Part A Effective Date: _________________   Medicare Part B Effective Date ___________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Medicare Part C (Medicare Advantage) Effective Date: _________________ Medicare Part D Effective Date: __________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 If "Yes," please complete the following table and attach a copy of the Certificates of Creditable Coverage for each person. Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 Type of Coverage Key:   G = Group Comprehensive Major Medical; I = Individual Comprehensive Major Medical; Microsoft Windows NT 6.1.7601 Service Pack 1   M = Medicare Supplement; D = Drug Coverage Only; H = Hospital Coverage Only; V = Vision Coverage Only - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: ____________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Product Type: _______________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Coinsurance Option: _______________ Deductible Option: _______________ Copayment Option: _______________ Microsoft Windows NT 6.1.7601 Service Pack 1 Selected Provider is for (choose only one): [ ] Health Insurance [ ] Dental Insurance [ ] Other ________________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: ____________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Product Type: _______________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Coinsurance Option: _______________ Deductible Option: _______________ Copayment Option: _______________ Microsoft Windows NT 6.1.7601 Service Pack 1 Selected Provider is for (choose only one): [ ] Health Insurance [ ] Dental Insurance [ ] Other _________________________ - See PDF for table - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 Availability of coverage is determined by your employer and whether the coverage is approved for issuance by the insurer(s). Microsoft Windows NT 6.1.7601 Service Pack 1 Please list the insurer(s) below from whom you are applying for coverage and check all benefits for which you are applying. Microsoft Windows NT 6.1.7601 Service Pack 1 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." Microsoft Windows NT 6.1.7601 Service Pack 1 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 Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Employee   [ ] Employee and Spouse   [ ] Employee and Dependent Child(ren) Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Employee, Spouse and Dependent Child(ren) Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Within the past 12 months, have you, your spouse or your dependent child(ren) had any individual or other group dental coverage? [ ] Yes [ ] No Microsoft Windows NT 6.1.7601 Service Pack 1 If "Yes," please provide the following information: Microsoft Windows NT 6.1.7601 Service Pack 1 Orthodontia coverage? [ ] Yes [ ] No Microsoft Windows NT 6.1.7601 Service Pack 1 Dental Insurer Name: _______________________________ Policy Number: ____________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Address: __________________________________________ Phone Number: ____________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Coverage Effective Date: __________________   Termination Date: ____________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Is coverage still in effect? [ ] Yes [ ] No Microsoft Windows NT 6.1.7601 Service Pack 1 Who was or is covered under the policy listed above? _____________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Please attach copies of Certificates of Prior Coverage. - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: __________________________________________ Insurer: __________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: __________________________________________ Insurer: __________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Employee Life/AD&D Amounts :   Basic Issue $__________ Supplemental $__________ Optional $__________ Microsoft Windows NT 6.1.7601 Service Pack 1 Primary Beneficiary Name ________________________________ Beneficiary's Social Security ___________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Relationship of Beneficiary _____________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Secondary Beneficiary Name ______________________________ Beneficiary's Social Security ___________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Relationship of Beneficiary _____________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Dependent Life Amounts:   Basic Issue $__________ Supplemental $__________ Optional $__________ Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Dependent Spouse Only [ ] Dependent Child(ren) Only [ ] Dependent Spouse and Dependent Child(ren) - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Short Term Disability   [ ] Long Term Disability Your Annual Salary $__________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Basic Benefit Amount $______________/ per week   Optional Benefit Amount $_____________/ per week - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Employee   [ ] Employee and Spouse   [ ] Employee and Dependent Child(ren) Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Employee, Spouse and Dependent Child(ren) Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Employee   [ ] Employee and Spouse   [ ] Employee and Dependent Child(ren) Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Employee, Spouse and Dependent Child(ren) Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 I understand that I am eligible to apply for coverage through my employer. I do NOT want coverage for (check all that apply): Microsoft Windows NT 6.1.7601 Service Pack 1 Employee:   [ ] Dental [ ] Basic Life/AD&D [ ] Supplemental Life/AD&D [ ] Optional Life Microsoft Windows NT 6.1.7601 Service Pack 1     [ ] Basic Disability [ ] Optional Disability [ ] Drug [ ] Vision Microsoft Windows NT 6.1.7601 Service Pack 1 Spouse:   [ ] Dental [ ] Basic Life [ ] Supplemental Life [ ] Optional Life [ ] Drug [ ] Vision Microsoft Windows NT 6.1.7601 Service Pack 1 Dependent Child(ren):   [ ] Dental [ ] Basic Life [ ] Supplemental Life [ ] Optional Life [ ] Drug [ ] Vision Microsoft Windows NT 6.1.7601 Service Pack 1 The reason I am waiving group coverage at this time is because of: Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Spousal coverage [ ] Individual Coverage [ ] Medicare [ ] Medical Assistance Microsoft Windows NT 6.1.7601 Service Pack 1 [ ] Other: _____________________________________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Employee: ______________________________________ Date Signed: __________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Spouse: _________________________________________ Date Signed: __________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Employee: ___________________________________________ Date Signed: __________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Spouse: _____________________________________________ Date Signed: __________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of each listed dependent who has attained the age of 18: Microsoft Windows NT 6.1.7601 Service Pack 1 ________________________________________ Date Signed: ___________ Print Name _______________________ Microsoft Windows NT 6.1.7601 Service Pack 1 ________________________________________ Date Signed: ___________ Print Name _______________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Complete this section if someone assisted you in the completion of this Application. Microsoft Windows NT 6.1.7601 Service Pack 1 The following person assisted me in completing the Application: ____________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Please explain your relationship with the Applicant: ______________________________________________________ - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 I. Protected Health Information Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 II. Purpose of this Authorization Form Microsoft Windows NT 6.1.7601 Service Pack 1 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"). Microsoft Windows NT 6.1.7601 Service Pack 1 III. Entities Authorized to Use and Disclose My Protected Health Information Microsoft Windows NT 6.1.7601 Service Pack 1 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: Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Insurer: _________________________________________ Insurer: ________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 IV. Term of Authorization Microsoft Windows NT 6.1.7601 Service Pack 1 I agree this Authorization shall be valid for two and one half (2 ½ ) years from the latest signature date below. Microsoft Windows NT 6.1.7601 Service Pack 1 V. Right to Revoke Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 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.) Microsoft Windows NT 6.1.7601 Service Pack 1 _________________________________   ________________   _________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Adult Applicant   Date signed   Printed Name Microsoft Windows NT 6.1.7601 Service Pack 1 _________________________________   ________________   _________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Spouse (if applicable)   Date signed   Printed Name - See PDF for table Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 ___________________________________   ________________   _________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Adult Dependent   Date signed   Printed Name Microsoft Windows NT 6.1.7601 Service Pack 1 ___________________________________   ________________   _________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Parent or Legal Guardian   Date signed   Name of Minor Child (please print)
for Minor Child(ren) (if applicable) Microsoft Windows NT 6.1.7601 Service Pack 1 If signing for more than one child, please list the names of each child for whom you are signing: Microsoft Windows NT 6.1.7601 Service Pack 1 _________________________________________   _________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Name of Minor Child (please print)   Name of Minor Child (please print)   Microsoft Windows NT 6.1.7601 Service Pack 1 _________________________________________   _________________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Name of Minor Child (please print)   Name of Minor Child (please print)   Microsoft Windows NT 6.1.7601 Service Pack 1 For services received by a minor that under state law the minor may consent to treatment without parental or legal guardian consent: Microsoft Windows NT 6.1.7601 Service Pack 1 ___________________________________   ________________   _________________________________ Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Parent or Legal Guardian   Date signed   Name of Minor Child (please print)
for Minor Child (if minor received
treatment with knowledge of parent) Microsoft Windows NT 6.1.7601 Service Pack 1 ___________________________________   ________________   _________________________________
Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Minor Child (if minor may   Date signed   Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization) Microsoft Windows NT 6.1.7601 Service Pack 1 ___________________________________   ________________   _________________________________
Microsoft Windows NT 6.1.7601 Service Pack 1 Signature of Minor Child (if minor may   Date signed   Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization) Microsoft Windows NT 6.1.7601 Service Pack 1 Uniform Employee Application
OCI 26-501 (R 6/2010) Microsoft Windows NT 6.1.7601 Service Pack 1