Illinois Department Of Public Health Medical Marijuana Application Details

There's a new application in town and it's shaking up the healthcare industry. Welcome to the Standard Health Application Form (SHAF), the latest and greatest way to apply for health insurance. Whether you're self-employed or work for a company that doesn't offer benefits, ShAF is perfect for you! With its simple online interface, you can apply for coverage in minutes. Plus, there are no hidden fees - what you see is what you get! So why wait? Get started today and join the thousands of Americans who have already made the switch to ShAF.

This information will aid you to understand better the details of the standard health application before you begin filling it out.

QuestionAnswer
Form NameStandard Health Application
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesillinois standard application provider, illinois standard health, illinois standard health for small employers, illinois depart of public health application

Form Preview Example

I L L I N O I S Standard Health Employee Application F O R SMALL Employers

INSURER USE ONLY

Policy/Group No.

Section No.

Effective Date

New Hire Waiting Period

For assistance in completing this application, please contact your employer or insurance agent. For information about your health insurance rights under state and federal law, and other resources, please contact the Illinois Department of Insurance’s Office of Consumer Health Insurance toll free at (877) 527-9431.

THIS standard application is intended to simplify your health insurance application process. You WILL only need to complete this one application, EVEN when your employer has requested quotes from multiple insurance companies.

The information you provide in this application will be sent to the following insurance companies: (To be completed by employer)

Insurer:

 

Insurer:

 

Insurer:

Insurer:

 

 

Insurer:

 

 

Insurer:

TO BE COMPLETED BY EMPLOYER

Employer Name:

Phone #:

 

 

Address:

REA son For EnrollmEnt (MARK ALL that apply)

 

New E nROl l MenT:

New Group

 

Open Enrollment New Hire (DaTe:

 

 

 

 

 

 

 

 

 

)

 

Late Enrollee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Speci al E nROl l MenT :

Adoption

Court Order Dependent Addition

Divorce Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

LOSS OF Coverage

MaRRiaGe

 

 

NewbORn

 

OTheR

DaTe Of Event:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E Mpl OyMent ST aT us:

Active Retiree (ReTIReMenT Date:

 

/

 

/

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Illinois Continuation

 

COBRA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee Dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QualifyinG EvenT:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STaRT Date

 

 

/

 

/

 

 

 

PROjecTed End Date

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

EMPl OY Ee I nF ORMA T i On

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last)

 

 

 

 

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Job Title:

 

 

 

 

 

 

 

 

 

 

 

 

 

Hire Date:

 

 

 

 

 

 

 

 

 

 

 

Hrs/Week:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status: Married Single

Divorced Widowed

Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apt #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home (OR CELL) PHONE: (

)

 

 

 

 

 

 

 

 

 

 

Business Phone: (

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address (optional):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

COVERAGE Requested

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MeDi Cal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee: Yes

No

 

 

 

 

Spouse/Domestic Partner: Yes

No

 

Child(ren): Yes No

 

 

Plan Choice:

 

 

 

 

 

Plan Choice:

 

 

 

 

 

 

 

 

 

 

 

Plan Choice:

 

 

 

 

 

 

 

 

If you are Wai vi ng ( DeCl i ni nG)

coverage for yourself or any member of your family, you must complete Section C

 

 

below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aetna Health Inc. NAIC No.: 95109

GR-67834-49 (1-11)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(V1) IL R-POD A

 

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer NAME

 

Employee NAME

 

 

C

WAi V Er Of COV ER AGe

Please complete this section only if you are Wai vi ng ( DeCl i ni ng) Coverage for yourself or one or more of your family members.

I acknowledge that I HAVE been given the opportunity to apply for group coverage available to me and my dependents through my employer.

I understand and agree:

If I am declining coverage for myself, my spouse/domestic partner, or my dependent Child(ren) because of other

coverage, I may in the future be able to enroll myself, my spouse/domestic partner, or my dependent Child(ren) provided that I request enrollment within 31 days after the other coverage ends.

If I HAVE a new spouse/domestic partner or child as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my new spouse/domestic partner or child provided that I request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

If I decide to request coverage in the future, for a reason other than the termination of other coverage or the addition of a new spouse/domestic partner or child, I may be considered a late enrollee, if applicable, or I may have to wait until the plan’s next open enrollment period. I also understand that as a late enrollee, coverage for preexisting conditions may be excluded for up to a period of 18 months. This period may be offset by the time I, my spouse/domestic partner, or my dependent Child(ren) was covered under a qualified health plan.

I certify that I was not pressured, forced, or unfairly induced by my employer, the agent, or the insurer(s) into waiving or declining the group coverage.

IDO NOT want, and hereby waive, coverage for (i ni T i al next to all that apply):

Medical for

 

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

 

 

Dental

for

 

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

 

 

Vision

for

 

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

 

Basic Lifefor

 

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

 

Dependent Life

for

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

 

Voluntary Life

for

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Short-Term DisabilityFOR

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

 

 

 

 

 

 

 

Long-Term Disabilityfor

[

] Myself

[

] My Spouse/Domestic Partner

[

] My Dependent Child(ren)

If offered.

Iam DeCl i ni ng group coverage for the following reason(s): (check all that apply)

Spouse/Domestic Partner’s Employer Plan

Individual Coverage (Non-Group Plan)

COBRA/State Continuation

Medicare or other Government Program

Other (please explain):

If you are declining ALL coverage for ALL persons, please skip to the Acknowledgement & Signature SECTION oN page 10 of this ApplicATION.

 

 

(V1)

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

GR-67834-49 (1-11)

2

Aetna Health Inc. NAIC No.: 95109

 

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer NAME

 

Employee NAME

 

 

D

I Ndi Vi dU Als REqU ESt i Ng COVER AGe

List yourself and all eligible family members to be included under coverage.

Please check with your employer or insurance agent about who may qualify as an eligible family member under the policy.

Illinois’ Young Adult Dependent Coverage law allows parents to cover children up to the age of 26, and up to age 30 for military veteran dependents, regardless of whether the child may be considered a dependent for tax or other purposes. For more information, please visit the Illinois Department of Insurance website at wwwH.insurance.illinois.gov.

NoT e: For purposes of this application, an “eligible military veteran” is a veteran who served in the active or reserve components of the U.S. Armed Forces, including the National Guard, and who received a release or discharge other than a dishonorable discharge.

 

I f additional space I S required, please ATTACH a separ ate sheet and BE sure T O sign an d date THAT sheet.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPl Oyee NaMe (Last)

 

 

 

 

 

 

(First)

 

 

 

 

 

 

 

(MI)

 

 

 

 

Social Security Number:

 

 

 

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

Height:

ft.

 

 

in.

 

Gender: Male

Female

 

HMO only (if/whEn AppLICAbLE): Primary Care Physician:

 

 

 

 

 

 

 

 

Physician ID:

 

 

 

 

 

 

 

 

 

 

 

SPouse/ DomesT ic ParT ner Name (Last)

 

 

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

(MI)

 

 

 

 

SoCIAl Security Number:

 

 

 

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

Height:

ft.

 

 

in.

 

Gender: Male

Female

 

HMO only (if/whEn AppLICAbLE): Primary Care Physician:

 

 

 

 

 

 

 

 

Physician ID:

 

 

 

 

 

 

 

 

 

 

 

Dependent Name (Last)

 

 

 

 

 

 

(First)

 

 

 

 

 

 

 

(MI)

 

 

Social Security Number:

 

 

 

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

Height:

ft.

 

 

in.

 

Gender: Male

Female

 

Eligible Military Veteran: Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO only (if/whEn AppLICAbLE): Primary Care Physician:

 

 

 

 

 

 

 

 

Physician ID:

 

 

 

 

 

 

 

 

 

 

 

Dependent Name (Last)

 

 

 

 

 

 

(First)

 

 

 

 

 

 

 

(MI)

 

 

Social Security Number:

 

 

 

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

Height:

ft.

 

 

in.

 

Gender: Male

Female

 

Eligible Military Veteran: Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO only (if/whEn AppLICAbLE): Primary Care Physician:

 

 

 

 

 

 

 

 

Physician ID:

 

 

 

 

 

 

 

 

 

 

 

Dependent Name (Last)

 

 

 

 

 

 

(First)

 

 

 

 

 

 

 

(MI)

 

 

Social Security Number:

 

 

 

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

Height:

ft.

 

 

in.

 

Gender: Male

Female

 

Eligible Military Veteran: Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO Only (if/whEn AppLICAbLE): Primary Care Physician:

 

 

 

 

 

 

 

 

Physician ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(V1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

GR-67834-49 (1-11)

 

 

 

 

3

 

 

 

 

 

 

 

Aetna Health Inc. NAIC No.: 95109

 

 

 

 

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer NAME

 

 

 

 

Employee NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent Name (Last)

 

 

 

 

 

(First)

 

 

 

 

 

(MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

 

 

 

 

 

Date of Birth:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight:

lbs.

Height:

ft.

in.

 

 

Gender: Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eligible Military Veteran: Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HMO only (if/whEn AppLICAbLE): Primary Care Physician:

 

 

 

 

Physician ID:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

CUR R E NT / PR i OR COV E R A GE I NF OR MA T i ON

Please indicate for EACH person listed on this application any health coverage, including Medicare or Medicaid, in effect within 24 monT hs prior to the proposed effective date of this coverage. Each person applying for coverage must be listed below. If no health care coverage was in effect within the past 24 monT hs, please indicate NONE. If coverage is provided for a dependent from a previous marriage or relationship, please attach a copy of the court DOCUMENTATION showing who is responsible for the dependent(s)’ health care coverage so that the insurer can determine whose coverage is primary.

NU oT e:U If you have had health care coverage within the last 63 days, your Pre-Existing Condition (PEC) waiting period limitation may be partially or completely waived. To determine if this applies to you, you must provide proof of prior coverage, such as a Certificate of Creditable Coverage from your previous insurer. Submission of prior coverage information does not automatically waive any PEC limitation. You will be subject to an automatic PEC Waiting Period of up to 12 months until the insurer receives evidence of prior coverage.

If additional space is required, please attach a separate sheet and be sure to sign and date that S H E E T .

Employee Name (LaST)

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

 

 

 

(MI)

 

 

 

 

 

 

 

 

 

 

CurrenT /Most Recent Coverage:

Group Medical

Dental

Individual Medical None

 

Dates of Coverage: From:

 

/_

 

/_

 

 

 

To:

 

 

/_

 

/_

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

Will the individual continue this coverage? Yes No

Prior Coverage ( if any): Group Medical

Dental

Individual Medical

None

 

Dates of Coverage: From:

/_

 

 

/_

 

 

To:

/_

/_

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse/ DomesT i c ParT ner Name (LaST)

 

 

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

(MI)

 

 

 

 

 

 

 

CurrenT /Most Recent Coverage: Group Medical

Dental

Individual Medical None

 

Dates of Coverage: From:

/_

 

 

/_

 

 

To:

/_

/_

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

Will the individual continue this coverage? Yes No

Prior Coverage ( if any): Group Medical

Dental

Individual Medical

None

 

Dates of Coverage: From:

/_

 

/_

 

 

To:

/_

/_

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent Name (LaST)

 

 

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

 

 

(MI)

 

 

 

 

 

 

CurrenT /Most Recent Coverage: Group Medical

Dental

Individual Medical None

 

Dates of Coverage: From:

/_

 

/_

 

 

To:

/_

/_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POlicyhOlder Name:

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

Will the individual continue this coverage? Yes No

 

Pri Or COveraGe ( if any): Group Medical

Dental Individual Medical

None

 

Dates Of COveraGe: FroM:

/_

 

/_

 

To:

/_

/_

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(V1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

GR-67834-49 (1-11)

 

 

 

 

 

4

 

 

 

 

 

 

Aetna Health Inc. NAIC No.: 95109

 

 

 

 

 

 

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer NAME

 

 

 

 

Employee NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent Name (LaST)

 

 

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

 

(MI)

CurrenT /Most Recent Coverage: Group Medical

Dental Individual Medical

None

Dates of Coverage: From:

/_

 

/_

 

 

 

To:

/_

/_

 

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

Will the individual continue this coverage? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prior Coverage ( if any): Group Medical

Dental

Individual Medical

None

 

 

 

 

 

 

 

Dates of Coverage: From:

/_

 

/_

 

 

 

To:

/_

/_

 

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent Name (LaST)

 

 

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

 

(MI)

CurrenT /Most Recent Coverage: Group Medical

Dental Individual Medical

None

Dates of Coverage: From:

/_

 

/_

 

 

 

To:

/_

/_

 

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

Will the individual continue this coverage? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prior Coverage ( if any): Group Medical

Dental

Individual Medical

None

 

 

 

 

 

 

 

Dates of Coverage: From:

/_

 

/_

 

 

 

To:

/_

/_

 

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent Name (LaST)

 

 

 

 

 

 

 

 

 

(FIRST)

 

 

 

 

 

 

 

(MI)

 

 

 

 

 

 

CurrenT /Most Recent Coverage: Group Medical

Dental Individual Medical

None

Dates of Coverage: From:

/_

 

/_

 

 

 

To:

/_

/_

 

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

Will the individual continue this coverage? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prior Coverage ( if any): Group Medical

Dental

Individual Medical

None

 

 

 

 

 

 

 

Dates of Coverage: From:

/_

 

/_

 

 

 

To:

/_

/_

 

 

 

 

 

 

 

Policyholder Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INsurer Name:

 

 

 

 

 

 

 

 

 

 

 

MEDI CA RE : If you or any family members listed on this application have Medicare coverage, please

COMPLETE the following information.

Enrol l i ng I ndi vi dual Name (LaST)

 

 

 

 

 

(FIRST)

 

(MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicare Part A

Part B Part D

Medicare Number (PLEASE INCLUDE

alpha PREFIX):

Effective Date:

 

/_

 

/_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for Medicare Entitlement: Age Disability ERSD Dual Enrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enrol l i ng I ndi vi dual Name (LaST)

 

 

 

 

 

(FIRST)

 

 

(MI)

 

 

 

 

 

Medicare Part A

Part B Part D

Medicare Number (PLEASE INCLUDE

Effective Date:

 

/_

 

/_

 

 

 

 

 

alpha PREFIX):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for Medicare Entitlement: Age Disability ERSD Dual Enrollment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(V1)

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

GR-67834-49 (1-11)

5

Aetna Health Inc. NAIC No.: 95109

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer NAME

 

Employee NAME

 

 

FHEAlTh ST AT EMENT

I nsT rucT ions:

1.The information you provide in this application is confidential. You should discuss with your employer if you prefer to submit the completed health statement directly to the insurance company or insurance broker.

2.The health information you provide below will be used by the insurance company to determine the price to charge your group for the coverage applied for and whether a Pre-Existing Condition Waiting PERIOD(S) WILL apply to your coverage. Coverage for pre-existing conditions cannot be limited or excluded for dependents under the age of 19.

3.Each medical question below applies to ALL persons requesting coverage.

4.Answer the questions below with either Yes or No. If you answer Yes to any question, you must provide additional information in Section G below.

5.Do not LEAVE any question unmarked.

6.Neither your employer nor your insurance agent can waive these requirements or may authorize you TO provide anything less than a complete and accurate response to each of the questions.

7.After you submit this application, the insurance company may call you to obtain additional confidential information needed to evaluate and aid the processing of your application.

1For the following conditions, Wi T hin T he past 5 years, have you or any dependents for whom you are requesting coverage:

Been tested for or diagnosed with;

Had medical treatment recommended;

Received medical 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

Yes

No

 

 

other disease or disorder of the heart, arteries, blood, or blood vessels?

 

 

 

 

 

 

B. Cancer or cancerous tumor?

 

Yes

No

 

 

 

C. Asthma, emphysema, tuberculosis, or any other disorder of the lungs or

Yes

No

 

 

respiratory system?

 

 

 

 

 

 

 

D. Diabetes? If yes, check ALL that apply:

 

Yes

No

 

 

Non-Insulin Dependent Insulin Dependent

Insulin Pump

 

 

 

 

 

 

E. Hepatitis, or any disorder of the liver, stomach, colon, or intestines?

Yes

No

 

 

 

F. Growth disorder or a disorder of the pancreas?

 

Yes

No

 

 

 

G. Chronic kidney stones, or other disorders of the kidney, prostate, or bladder?

Yes

No

 

 

 

H. Reproductive organ disorders or infertility?

 

Yes

No

 

 

 

I. Arthritis, or any other disorder of the joints, muscles, back, or bones?

Yes

No

 

 

 

J. Mental or emotional disorder?

 

Yes

NO

 

 

 

K. Seizures/epilepsy, paralysis, or any other disorder of the brain or nervous

Yes

NO

 

 

system?

 

 

 

 

 

 

 

 

 

 

 

 

(V1)

 

 

 

 

 

 

 

 

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

GR-67834-49 (1-11)

6

Aetna Health Inc. NAIC No.: 95109

 

 

 

 

 

 

 

 

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

 

Employer NAME

 

 

 

 

 

 

 

Employee NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

L. HIV positive, AIDS, diseases associated with AIDS, lupus, or other disorder of

Yes

No

 

 

the immune system?

 

 

 

 

 

 

 

 

 

M. Alcohol, drug, or substance use or dependency?

Yes

No

 

 

N. Organ or bone marrow transplant?

Yes

No

 

 

 

 

 

2 Are you, your spouse/domestic partner, or any dependent for whom you are requesting

Yes

No

 

 

coverage currently pregnant?

 

 

 

 

 

 

 

Due Date:

 

/_

 

/_

 

(MM/DD/YYYY)

 

 

 

 

If yes, are multiples (twins, triplets, ETC.) expected?

Yes

No

 

 

Are there any known complications, or is a cesarean section planned?

Yes

No

 

3Wi T hin T he past 12 monT hs, have you or your spouse/domestic partner

 

used any tobacco products?

Employee:

Yes

No

 

 

Spouse/Domestic Partner:

Yes

No

 

 

 

 

4

Wi T hin T he past 12 monT hs, has any applicant been prescribed medication

Yes

No

 

(other than for the common cold or flu) that is not i ndi caT ed el seWhere i n

 

 

 

T his appl i caT ion?

 

 

 

 

 

 

 

5

Wi T hin T he past 5 years, has any person applying for coverage been tested for or

Yes

No

 

diagnosed with, had medical treatment recommended, received medical treatment,

 

 

 

including prescription medications, or been hospitalized for any i l l ness, i nj ury or

 

 

 

heal Th condi T ion not i ndi caT ed above?

 

 

 

G

ADDi T i ONA l I NF OR MA T i ON

 

If you ansWered “ Yes” To any of T he quesT ions above, you must compl eTe T his secT ion.

 

If additional space is required, please attach a separate sheet and be sure to sign and date that S H E E T .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuesTIOn NuMBer:

 

NaMe oF InDividual:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition/Diagnosis:

 

 

 

 

 

 

 

Date Diagnosed (MM/YYYY):

 

 

 

TreaTMenT ReceIVEd:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment ongoing? Yes No

Last Treatment Date:

 

 

 

 

 

 

 

 

 

 

 

Surgery, additional tests or treatment recommended?

 

 

 

 

 

 

 

 

 

 

MedicaTIOn Prescribed (IF anY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently taking medication? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuesTIOn NuMBer:

 

NaMe oF InDividual:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition/Diagnosis:

 

 

 

 

 

 

 

Date Diagnosed (MM/YYYY):

 

 

 

TreaTMenT ReceIVEd:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment ongoing? Yes No

Last Treatment Date:

 

 

 

 

 

 

 

 

 

 

 

Surgery, additional tests or treatment recommended?

 

 

 

 

 

 

 

 

 

 

MedicaTIOn PreSCribed (IF anY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently taking medication? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(V1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

GR-67834-49 (1-11)

 

 

7

 

 

Aetna Health Inc. NAIC No.: 95109

 

 

 

 

 

 

 

 

 

 

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

 

Employer NAME

 

 

 

 

Employee NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuesTIOn NuMBer:

NaMe oF InDividual:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition/Diagnosis:

 

 

 

 

 

 

 

 

Date Diagnosed (MM/YYYY):

 

 

 

 

TreaTMenT ReceIVEd:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment ongoing? Yes No

Last Treatment Date:

 

 

 

 

 

 

 

 

 

 

 

 

Surgery, additional tests or treatment recommended?

 

 

 

 

 

 

 

 

 

 

 

 

MedicaTIOn Prescribed (IF anY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently taking medication? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuesTIOn NuMBer:

 

NaMe oF InDividual:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition/Diagnosis:

 

 

 

 

 

 

 

 

Date Diagnosed (MM/YYYY):

 

 

 

 

TreaTMenT ReceIVEd:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment ongoing? Yes No

Last Treatment Date:

 

 

 

 

 

 

 

 

 

 

 

 

Surgery, additional tests or treatment recommended?

 

 

 

 

 

 

 

 

 

 

 

 

MedicaTIOn Prescribed (IF anY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently taking medication? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuesTIOn NuMBer:

 

NaMe oF InDividual:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition/Diagnosis:

 

 

 

 

 

 

 

 

Date Diagnosed (MM/YYYY):

 

 

 

 

TreaTMenT ReceIVEd:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment ongoing? Yes No

Last Treatment Date:

 

 

 

 

 

 

 

 

 

 

 

 

Surgery, additional tests or treatment recommended?

 

 

 

 

 

 

 

 

 

 

 

 

MedicaTIOn Prescribed (IF anY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently taking medication? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuesTIOn NuMBer:

NaMe oF InDividual:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition/Diagnosis:

 

 

 

 

 

 

 

 

Date Diagnosed (MM/YYYY):

 

 

 

 

TreaTMenT ReceIVEd:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment ongoing? Yes No

Last Treatment Date:

 

 

 

 

 

 

 

 

 

 

 

 

Surgery, additional tests or treatment recommended?

 

 

 

 

 

 

 

 

 

 

 

 

MedicaTIOn Prescribed (IF anY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently taking medication? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QuesTIOn NuMBer:

 

NaMe oF InDividual:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Condition/Diagnosis:

 

 

 

 

 

 

 

 

Date Diagnosed (MM/YYYY):

 

 

 

 

TreaTMenT ReceIVEd:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment ongoing? Yes No

Last Treatment Date:

 

 

 

 

 

 

 

 

 

 

 

 

Surgery, additional tests or treatment recommended?

 

 

 

 

 

 

 

 

 

 

 

 

MedicaTIOn PreSCribed (IF anY):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Currently taking medication? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(V1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

GR-67834-49 (1-11)

 

 

8

 

 

Aetna Health Inc. NAIC No.: 95109

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer NAME

 

Employee NAME

 

 

H

Addi T i ONAl COV ERAGE OpT i ONS

You should compl eTe T his secT ion only if your employer offers any of T he addi T ional coverage opT ions

beloW.

Employee

Dental: PPO HMO

Dental HMO Office ID # (IF applicable):

Vision Basic Life

Dependent Life Voluntary Life: AmounT (IF applicable): $

Short- TERM Disability

Long- TERM Disability

Employee Class (Employer Will provide you With THis infoRMaTIOn IF needed):

Salary (IF requesting LIFE or disability coverage): $

Hourly Weekly Monthly Semi-monthly Annually

Spouse/ DomesT ic ParT ner

Dental: PPO HMO

Dental HMO Office ID # (IF applicable):

Vision Basic Life

Dependent Life Voluntary Life: AmounT (IF applicable): $

 

 

Short- TERM Disability

Long- TERM Disability

 

 

 

 

Chi l d( ren)

 

 

 

Dental: PPO HMO

Dental HMO Office ID # (IF applicable):

Vision Basic Life

Dependent Life Voluntary Life: AmounT (IF applicable): $

Short- TERM Disability

Long- TERM Disability

Benefi ci ary I nformaT ion (if requesting

life insurance)

 

 

 

 

 

 

 

 

 

 

Primary Beneficiary Name (Last, First, MI)

 

 

 

 

 

 

 

 

RelaTIOnship

 

 

 

Benefit %

 

 

 

 

 

 

 

 

 

 

Secondary Beneficiary Name (Last, First,

MI)

 

 

RelaTIOnship

 

 

 

Benefit %

 

 

 

 

 

 

 

 

 

 

 

 

 

(V1)

 

 

Aetna Life Insurance Company NAIC No.:

001-60054

GR-67834-49 (1-11)

9

Aetna Health Inc. NAIC

No.: 95109

 

 

ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER

Employer NAME

 

Employee NAME

 

 

ACkNoWl ED gEmENT & Si gNAT URE

I understand, agree, and represent that:

I HAVE read this document or it has been read to me.

The answers provided within this entire application for coverage are, to the best of my knowledge and belief, true and complete.

Neither my employer nor the agent has the authority to waive a complete answer to any question, determine coverage or insurability, alter any contract, or waive any of the insurance carrier’s other rights and requirements.

I UNDERSTAND that if I intentionally omit or provide false information on or in relation to this application, then this policy may be cancelled retroactively, in which case any claim I submit may not be paid by the insurer. I UNDERSTAND that if I intentionally omit or provide false information on or in relation to this application that I may face legal liability, including legal action based on fraud.

If this application for coverage is accepted, coverage will be effective on the date specified by the insurance carrier on the certificate of coverage/certificate of insurance.

I hereby enroll for benefits as indicated in Section B and Section H of this application, for which I am presently eligible or for which I may become eligible under my employer’s group contract(s). If any 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.

I UNDERSTAND that the INFORMATION I HAVE provided in this application will be used by the insurance carrier and its affiliates to make decisions regarding eligibility, enrollment, underwriting, and premium risk rating.

I UNDERSTAND that the medical information provided also includes my spouse/domestic partner and/or dependents’ information.

I UNDERSTAND that I may be asked for authorization to disclose my medical, claim, or benefit records at a later TIMe.

I understand that I should retain a duplicate copy of this application for my own records.

A photographic copy of this acknowledgment shall be as valid as the original.

I authorize the insurance carrier to electronically transmit the information contained herein.

If this application was taken over the phone or on the computer, I acknowledge that I, myself, have not actually signed this application but instead hereby authorize the insurance carrier to print “Electronically Acknowledged” on THe signaTUre LINE of the application and I agree that such printing shall be treated as a valid signature for all purposes of this form. I acknowledge that the insurance carrier has verified my identity for this purpose in accordance with any applicable law or regulation.

By signing below, I acknowledge that I HAVE read and understand this document and I am signing of my own free will.

EmPloyee SignaT ure

 

DaT e

For assistance in completing this application, please contact your employer or insurance agent.

For information about your health care rights under state and federal law, and other resources, please contact THe Illinois Department of Insurance’s Office of Consumer Health Insurance toll free at (877) 527-9431.

 

 

(V1)

 

 

Aetna Life Insurance Company NAIC No.: 001-60054

GR-67834-49 (1-11)

10

Aetna Health Inc. NAIC No.: 95109