Insurance Application Details

When applying for health insurance, there are a few things you will need to have on hand. The first is your social security number. You will also need to know the name of your current insurance company and policy number, if you have one. If you do not have health insurance, you will need to provide information about your income and family size.Knowing what documentation is needed when filling out a health insurance application can help ensure a smooth process. Having all of the required information ready will save time and hassle in the long run.

Here is the details about the form you were looking for to complete. It can show you the length of time you'll need to finish health insurance application, exactly what fields you will need to fill in and a few other specific details.

QuestionAnswer
Form NameHealth Insurance Application
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesinsurance application, health insurance form, health insurance application form, medical insurance application form

Form Preview Example

UTAH SMALL EMPLOYER HEALTH INSURANCE APPLICATION

OFFICE USE ONLY

Policy / Group No.

Effective Date

PEC

New Hire Waiting Period

A. EMPLOYER INFORMATION

REASON FOR ENROLLMENT (mark all that apply)

New Group

Newborn

Loss of Coverage____________________

 

 

 

Open Enrollment

Court Order

Marriage____________________

New Hire

Dependent Addition

Divorce_____________________

 

 

 

New Application

Other:___________

Military Leave of Absence(USERRA)________

COBRA

Utah mini-COBRA

Alternative Coverage (Utah NetCare) for:

Employee Dependent(s)

Length of continuation coverage: 12 mos. 18 mos. 36 mos. Other:

Original Qualifying Event Date:

Qualifying Event Date:

Date of Event:

 

 

 

WAIVER OF COVERAGE Individuals waiving coverage complete only Section J.

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hire Date

 

 

 

 

 

 

Rehire Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location

 

 

 

 

 

 

 

 

 

Is this a division? Yes No If “Yes,” name of parent company

 

 

 

 

 

 

 

 

 

 

 

 

B. EMPLOYEE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last)

 

 

 

 

 

 

(First)

 

 

 

 

 

 

 

 

 

(MI)

 

 

Job Title

 

 

 

 

 

 

 

 

 

Hrs/Week

 

 

 

 

Marital Status Married

 

Single

Divorced

Widowed Domestic Partner*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

Apt.

 

 

 

City

 

 

 

 

 

 

 

 

State

 

 

 

Zip

 

 

 

 

 

 

Home (or other) Phone (

 

)

 

 

 

Business Phone (

)

 

 

 

 

 

 

 

Email Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s Business (or other) Phone (

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. ENROLLING EMPLOYEE / SPOUSE / DOMESTIC PARTNER* / DEPENDENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List yourself and all dependents applying for coverage. Attach a separate sheet if necessary.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

Social Security #

 

 

Date of Birth

 

Age

 

 

Gender

 

Weight

Height

 

 

 

 

 

 

 

 

 

 

 

(Last, First, Middle)

 

 

 

 

 

 

 

(for insurer use only)

 

MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

lbs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

Domestic Partner*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

lbs.

 

 

 

 

Dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

lbs.

 

 

 

 

Dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

lbs.

 

 

 

 

Dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Female

 

lbs.

 

 

 

D. CURRENT/PRIOR COVERAGE INFORMATION

Indicate any health care coverage, Medicaid, or Medicare in effect within the last 24 months. This will be used to determine if you have creditable coverage or if

benefits will be coordinated. If no health care coverage was in effect within the past 24 months, indicate NONE. If applicable, provide a copy of any applicable court documentation that shows who is responsible for the dependent(s)’ health care coverage. Attach a separate sheet if necessary.

 

Insurer (Including policyholder name,

Date of Coverage

 

Will

 

Type of Coverage

 

MM/YYYY

 

coverage

 

(Check all that apply)

 

insurer name and phone number) Medicaid or Medicare

 

 

 

Start Date End Date

 

continue?

 

 

 

 

 

 

 

 

 

Employee:

 

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

No

Medical

Dental

Other

Spouse/Domestic Partner*:

 

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

No

Medical

Dental

Other

 

 

 

 

 

 

 

 

 

Dependent:

 

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

No

Medical

Dental

Other

 

 

 

 

 

 

 

 

 

Dependent:

 

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

No

Medical

Dental

Other

 

 

 

 

 

 

 

 

 

Dependent:

 

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

No

Medical

Dental

Other

*Check with your employer to determine if domestic partner coverage is available.

 

 

 

 

 

Page 1 of 4

 

 

 

Utah Small Employer Health Insurance Application October 2010

E. HEALTH STATEMENT

EACH QUESTION MUST BE CHECKED "YES" OR "NO." ALL questions must be answered and complete or the application will be returned. It is your

responsibility to notify the insurer of any change in health status while this application is pending. The federal Genetic Information Nondiscrimination Act prohibits health insurers from requesting, requiring, purchasing, or collecting “genetic information” for underwriting purposes. DO NOT REPORT GENETIC

INFORMATION ON THIS FORM. Information about manifested diseases or conditions of an applicant is not considered genetic information and is to be reported, even if the disease or condition is caused by or associated with genetics. The information provided in this section may be used for rate setting, risk-adjustment or coordination of care, but will not be used to deny coverage.

HEALTH QUESTIONS

YES

NO

 

Is any applicant pregnant or financially responsible for an unborn child, or do you anticipate adopting a child in the next 12 months?

 

 

1

If currently pregnant, provide expected due date_________________________.

 

 

Do you anticipate complications or multiple births?

 

 

 

 

 

 

Have you had prior complications or multiple births?

 

 

 

 

 

2Within the past 12 months has any applicant:

A.Taken any prescribed medications for any health condition identified in Section E?

B.Been injected with a drug or medication by a health care provider excluding immunizations?

Are all applicants’ immunizations current?

3

Within the past 12 months has any applicant used any form of tobacco, including but not limited to cigars, cigarettes, or chewing

tobacco)? If applicant has quit using tobacco give approximate quit date:__________________________

 

 

Within the past 5 years, has any applicant applying for coverage been tested for or diagnosed with, had treatment recommended,

4received treatment, including prescription medications, or been hospitalized for any illness, injury, or health condition related to any of the categories listed below?

A.Cardiovascular disease or heart attack, stroke, high blood pressure, or any other diseases or disorders of the heart, arteries, blood, or blood vessels?

B.Asthma, emphysema, tuberculosis, or any other diseases or disorders of the lungs or respiratory system?

C.Diabetes or any other diseases or disorders of the pancreas? If yes, check all that apply:

 

Non Insulin Dependent Insulin Dependent Insulin Pump

 

D. Hepatitis or any other diseases or disorders of the liver, stomach, colon, or intestines?

 

E. Chronic kidney stones or any other diseases or disorders of the kidney, prostate, or bladder?

 

F. Male or female reproductive organs or any other diseases or disorders including infertility?

 

G. Arthritis or any other diseases or disorders of the joints, muscles, back, or bones?

 

H. Mental health diseases or disorders or alcohol/drug abuse?

 

I. Seizures/epilepsy, paralysis, or any other diseases or disorders of the brain or nervous system?

 

J.Lupus or any other diseases or disorders of the immune system?

5

Within the past 5 years, has any applicant applying for coverage been diagnosed or treated by a licensed medical professional for

HIV, AIDS, or AIDS Related Complex?

 

 

Within the past 5 years, excluding routine or preventative care, has any applicant applying for coverage been tested for or

6diagnosed with, had treatment recommended, received treatment, including prescription medications, or been hospitalized for any illness, injury or health condition not indicated above?

7

Has any applicant ever had any organ or tissue transplant?

8

Has any applicant ever had cancer (including skin cancer or melanoma)?

IF ANY OF THE QUESTIONS IN THIS SECTION WERE CHECKED “YES”, PROVIDE DETAILS IN SECTIONS F & G.

F. PRESCRIPTION INFORMATION WITHIN LAST 12 MONTHS Refer to Section E

IF ANY OF THE QUESTIONS IN SECTION E WERE CHECKED “YES”, PROVIDE DETAILS IN THIS SECTION. Attach a separate sheet if necessary.

Name of Applicant

Name of Medication

Reason for medication (Name of Illness,

Disorder or Treatment)

Start Date

MM /YYYY

End Date

MM/YYYY

Physician, clinic, or hospital name. If

known, provide phone number or address.

Page 2 of 4

Utah Small Employer Health Insurance Application October 2010

G. ADDITIONAL INFORMATION Refer to Section E

IF ANY OF THE QUESTIONS IN SECTION E WERE CHECKED “YES”, PROVIDE DETAILS IN THIS SECTION. Attach a separate sheet if necessary.

Question

#

Name of Applicant

Explain diagnosis, illness, injury, treatment received,

testing, consultations, future treatments, and

remaining symptoms or problems.

Diagnosis / Treatment Date(s)

Start Date

End Date

MM /YYYY

MM/YYYY

 

 

Physician, clinic, or hospital name. If

known, provide phone number or address.

H. DISABILITY INFORMATION

Are you or any dependent(s) disabled? Yes No If yes, indicate first and last name(s).___________________________________________________________

Reason for disability:___________________________________________________________________________________________________________________

Is the disabled individual currently unable to perform routine daily functions for two weeks or more? Yes No

Have you or any dependent(s) filed workers’ compensation claims or disability claims within the last five years? Yes No

If so, what is the status of the claims?_____________________________________________________________________________________________________

I. ACKNOWLEDGMENT AND SIGNATURE

I agree to abide by the insurer’s enrollment provisions. I understand that coverage cannot start until after the waiting period. I authorize my employer to act as my agent in all matters of administration of the group program, and acknowledge that my employer is in no way acting as agent for the insurer.

I acknowledge that I have had the opportunity to waive coverage for myself and any eligible dependents that I have listed those waiving coverage, if any, in Section J, “Waiver of Coverage” of this application.

I understand that credit for prior coverage will be based upon the information contained in this application and/or proof of prior coverage, such as a Certificate of Creditable Coverage.

If the policy contains a voluntary arbitration provision: ANY MATTER IN DISPUTE BETWEEN YOU AND THE INSURER MAY BE SUBJECT TO ARBITRATION AS AN ALTERNATIVE TO COURT ACTION PURSUANT TO THE RULES OF THE AMERICAN ARBITRATION ASSOCIATION OR OTHER RECOGNIZED ARBITRATOR, A COPY OF WHICH IS AVAILABLE ON REQUEST FROM THE INSURER. THE INSURER SHALL BEAR THE COSTS OF ARBITRATION, FILING FEES, ADMINISTRATIVE FEES AND ARBITRATOR FEES. OTHER EXPENSES OF ARBITRATION, INCLUDING, BUT NOT LIMITED TO: ATTORNEY FEES, EXPENSES OF DISCOVERY, WITNESSES, STENOGRAPHER, TRANSLATORS, AND SIMILAR EXPENSES, WILL BE BORNE BY THE PARTY INCURRING THOSE EXPENSES. ANY DECISION REACHED BY ARBITRATION SHALL BE BINDING UPON BOTH YOU AND THE COMPANY. THE ARBITRATION AWARD MAY INCLUDE ATTORNEY'S FEES, IF ALLOWED BY STATE LAW, AND MAY BE ENTERED AS A JUDGMENT IN ANY COURT OF PROPER JURISDICTION.

I certify that all information completed on this form is true, accurate, correct and complete. I acknowledge that if any information provided is false, the insurer may without advance notice pursue any remedies available under state or federal law, including declaring the coverage null and void and canceling the coverage retroactive to its original effective date.

I have read the Acknowledgment of this document and agree to its terms. I have also completed an authorization to disclose protected health information form, if such form accompanies this application.

Employee Signature_____________________________________________________________________________________Date__________________________

Page 3 of 4

Utah Small Employer Health Insurance Application October 2010

J. WAIVER OF COVERAGE

COMPLETE WHEN WAIVING COVERAGE FOR SELF AND/OR DEPENDENTS

Employer:

Employee Name: (Last)(First)(MI)

INDIVIDUALS WAIVING COVERAGE

Name of Individual

 

Date of Coverage

Will

 

Type of Coverage

Insurer and phone number

MM/YYYY

coverage

 

waiving coverage

 

(Check all that apply)

 

Start Date End Date

continue?

 

 

 

 

 

 

 

 

 

 

 

 

Employee:

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

 

 

 

No

Medical

Dental

Other

 

 

 

 

 

 

 

 

Spouse / Domestic Partner:

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

 

 

 

No

Medical

Dental

Other

 

 

 

 

 

 

 

 

Dependent:

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

 

 

 

No

Medical

Dental

Other

 

 

 

 

 

 

 

 

Dependent:

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

 

 

 

No

Medical

Dental

Other

 

 

 

 

 

 

 

 

Dependent:

 

 

 

Yes

Group

Individual

Governmental

 

 

 

 

 

 

 

 

No

Medical

Dental

Other

 

 

 

 

 

 

 

 

HEALTH STATEMENT

Pregnancy / Adoption: Is any individual waiving coverage pregnant or financially responsible for an unborn child? If currently pregnant, YES NO

provide expected due date: ___________________.

Do you anticipate complications or multiple births? Have you had prior complications or multiple births?

IF “YES”, PROVIDE DETAILS IN THIS SECTION Attach a separate sheet if necessary.

Name of Individual

Explain diagnosis, illness, treatment received, testing, consultations, future

treatments, and remaining symptoms or problems

Diagnosis/Treatment date(s)

Start Date

Start Date

MM /YYYY

MM /YYYY

 

 

Physician, clinic, or hospital name. If known,

provide phone number or address.

ACKNOWLEDGEMENT AND SIGNATURE

I acknowledge that I have had the opportunity to enroll, but do not wish to make application for those individual(s) listed above. In waiving coverage, I am aware that waiving individuals (including myself, if I am waiving) may not enroll until my group’s anniversary, unless the waiving individual qualifies for a Special Enrollment

Period (SEP). If I have waived enrollment for myself or any of my dependents (including my spouse) because of other health care coverage or group health plan

coverage, I may in the future be qualified for a SEP and be able to enroll the waived individuals in this plan, provided I request enrollment within 30 days after the other coverage of the individual(s) ends due to loss of eligibility or an employer’s ceasing to contribute toward that other coverage (within 60 days if the other

coverage was Medicaid or CHIP). In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I further certify that all information completed on this form is true, correct and complete, and acknowledge my coverage is subject to cancellation or other action permissible by law, if any completed information is found to be false or incorrect.

Employee Signature______________________________________________________________________________________Date___________________________

Page 4 of 4

Utah Small Employer Health Insurance Application October 2010

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