Comprehensive Group Dental Application Package

Transcription

1 Comprehensive Group Dental Application Package Contents: Submission Coversheet Employer Application Additional Information Questionnaire Member Enrollment Forms Employer Banking Authorization For Electronic Funds Transfer Guardian Anytime Pre-Registration GUARDIAN and the GUARDIAN G Logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission. Guardian's Dental policy is underwritten by The Guardian Life Insurance Company of America (Guardian), New York, NY. Providence Health Plan is authorized to offer certain Dental policies underwritten by Guardian but is not an affiliate or related entity of Guardian. LIFE DENTAL DISABILITY VISION CRITICAL ILLNESS ABSENCE MANAGEMENT EAP

2 New Business Submission Coversheet Complete and Submit to: The Guardian Life Insurance Company 222 South Mill Avenue, Suite 412 Tempe, AZ subject line: Providence Health Plan - [Employer Name] Employer Name: Date Submitted: Requested Effective Date: Submitter s Contact Info: Name Address Direct Phone No. Required Documents Application Package: o Submission Coversheet (this document) o Employer Application o Additional Information Questionnaire (AIQ) o Member Enrollment Forms o Employer Banking Authorization For Electronic Funds Transfer (if elected by employer) o Guardian Anytime Pre-registration Form Copy of Guardian Comprehensive Group Dental Rate Page (page reflecting rates of sold plan option) Deposit Check for the 1 st month s premium Copy of prior carrier bill (If required. Reference plan options chart below.) Please identify the sold plan design option by completing the table below: Please identify any additional sold plan option by completing the table below: *** Guardian Internal Use *** Channel Partner: Providence Health Plan Channel Partner ID: 00059

3 Please print clearly to ensure accurate processing The Guardian Life Insurance Company Of America 7 Hanover Square, New York, NY APPLICATION FOR A PLAN OF GROUP INSURANCE REQUESTED COVERAGE Coverage(s): Applicant Name : Your Insurance Broker is : Your Guardian Representative is : Broker Name Broker Address: Broker Phone: GR Name GR Address: GR Phone: Address : City : State : Zip : SIC Code : BUSINESS INFORMATION Types of Organization: Corporation Partnership Proprietorship Nature of Business S Corp Other: Tax ID Number Date Established MM/DD/YYYY Yes No Has your company ever filed, or is it now in the process of filing, for bankruptcy (Chapter 7 or 11)? Complete below if your company or any of its affiliates has ever applied for group insurance with Guardian. Company or Affiliate Name (If different from Section 1) Plan Number Cancellation Date MM/DD/YYYY Complete below if there are any COBRA or state continuation cases. Employee/Dependent Type Reason Continuation Dates For additional names, please attach a Date of Birth State Federal Disability Start End separate sheet MM/DD/YYYY Extension of benefits Non-Disability MM/DD/YYYY MM/DD/YYYY AGREEMENT Conditions Of Agreement It is understood that only full-time employees shall be eligible. Acceptance of Plan It is further understood that no insurance will be effective until the plan is accepted in writing by the Insurance Company(-ies). No contract of insurance is to be implied in any way on the basis of the completion and submission of the application. CMA2007 * * * * OR Page 1 of 3

4 AGREEMENT Continued Full-time employee means one who regularly works the number of hours in the normal work week established by this applicant (but not less than 30 hours per week) at the applicant s normal place of business. Insurance Broker Representation: It is further understood that no broker has power on behalf of The Guardian Life Insurance Company of America to make or modify any request or application for insurance, or to bind said Insurance Company by making any promise or representation or by giving and receiving any information. Upon acceptance, this application will be attached to and made part of the Group Insurance Policy. Trust. In the event that the Applicant has existing coverages with Guardian (other than GUL products) which were issued initially through a trust, Applicant acknowledges and agrees that such coverages along with the coverage described above may be re-issued directly to the Applicant as planholder, if applicable. Fraud Warning: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer, by submitting an application, or by filing a claim containing a false statement as to any material fact, may be violating state law. The undersigned applicant certifies that to the best of his/her knowledge and belief, all of the responses given are true, correct and complete. The applicant understands that a false statement or misrepresentation in the application may result in loss of coverage in the policy, the rescission of the policy, or a revision of the rates quoted. * * * * Page 2 of 3

5 SIGNATURES I have reviewed the statements made by me on this application, and they are true and complete to the best of my knowledge and belief. By my signature below, I acknowledge that endorses the Guardian plan of insurance. Officer, Partner or Proprietor Signature X Date MM / DD / YYYY Witness Signature X Date MM / DD / YYYY Title Title Insurance Broker Signature X Date MM / DD / YYYY Additional Insurance Broker Signature X Date MM / DD / YYYY Print Name Print Name CMA2007 OR Group Plan Number Requested Effective Date MM / DD / YYYY * * * * Page 3 of 3

6 Providence Health Plan Code Contact name Phone number The Guardian Life Insurance Company Of America Address Contact address white Company Name (As it should appear on your bill and contract) Plan Number(s) Requested Effective Date ADDITIONAL INFORMATION QUESTIONNAIRE Correspondent Name Phone Number Fax Number Correspondent Title Address Company Address Mailing Address (if different) City State Zip City State Zip Total Number of Employees Total Number of Employees Eligible for Coverage Are there any Additional Affiliate Locations? Yes (Please provide details, including name if different than company name) No (All out of state employees commute or work at home) Guardian is able to arrange incidental group coverage for US-sitused corporations in most countries. Depending on the countries where your employees are located, there may be a certain set of restrictions or exclusions applicable to benefit plans. Do you have any employees working outside the United States? Yes No If Yes, please provide details regarding the number of employees, and locations. 1. Affiliate Name Address Total Employed Eligible for Coverage Correspondent Name Phone Number Address Fax Number Please provide waiting period information. Applies to: (1) (2) Only employees hired after the effective date of coverage with Guardian All employees including those hired before, on, or after the effective date of coverage with Guardian Waiting Period: Coverage Ends: (A) (B) (C) (D) (E) days (actual calendar days counted) month(s) first of the month following days (actual calendar days counted) first of the month following month(s) first of the month following or coinciding with date hired First of the month effective dates give employees coverage until the end of the month for dental. Page 1

7 Requested Class Definitions. If classes of employees have different benefits or waiting periods define classes below or indicate Class 1 as "All eligible employees". For multiple classes, the employee class must be indicated on the enrollment form/census. Class Description Waiting period: If class specific, indicate letter and number from waiting period section Class 1 All eligible employees Applies to: 1 2 Waiting Period: A B C D E Please indicate any classes to be excluded. Final classes may be altered based on legal requirements or ease of administration. Are Retirees included? Yes No Rates assume no retiree coverage. Coverage for retirees requires prior underwriting approval. Does the company offer coverage for Domestic Partners? Yes No Select one: registered OR non-registered cchildrenrofrdomesticrpartnerrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr Employer Contribution Please complete this table listing the employer premium contribution. Dental Employee Employer pays all Employer pays $ Employer pays part % Employer pays none Dependent Employer pays all Employer pays $ Employer pays part % Employer pays none What is the minimum hourly work requirement for employees to be eligible for benefits? Minimum Hours Per Week (All Classes / All Coverages) All employees work the required minimum number of hours Explain if different by Class or Coverage Please provide prior carrier information Insert carrier name or select none Termination Date Dental none / / Annual Open Enrollment (for dental only) Check all that apply. Sign up period begins and ends Change Effective Type of open enrollment option From Date To Date Transfer Date Section 125 Buy-Up / Dual Choice None Dental / / / Billing Preferences Guardian s standard billing method is electronic bills. You will receive e-bills for viewing and payment through our secure website If you require a paper bill, please indicate below. Billing frequency: Monthly Quarterly Semi-Annual Annual Payroll frequency: 12/year 24/year 26/year 48/year 52/year Include Payroll Deduction Statements? Yes No Bill delivery electronic (standard) paper with volumes paper without volumes Standard List Bill - alphabetically by employee Subtotal billing Organize by (Check one): Class Job title Department Location By these codes (Up to 4 characters): DESCRIPTION Page 2

8 Division billing Send bills to: Individual Divisions Main Billing Office NOTE: All checks must be submitted by the due date. Must have a minimum of 10 employees in each division. Any single missed payment may result in cancellation of the entire plan. Main Billing Office/Division Name Office/Division Contact Name Address (if other than page 1) Telephone City State Zip Self-Administered (Available for plans with over 250 covered employees.) Would the company like to use Electronic Funds Transfer? Yes No Delivery Preference of Plan Materials. Administration Kit (select one): Mail to company Mail to insurance broker Mail to benefits advisor Mail to channel partner ID Cards: Electronic Member Level ID Cards or Electronic Plan Level ID Cards are available on Dental plans. Would you like Plan Level or Member Level Electronic Cards? Plan Level Member Level R Electronic Cards Claims In case of a claim, send as follows (select one) Employee check / EOB to employee home Other Master Application signed by: Title: printed name Insurance Broker Information (Broker Use Only) Insurance Broker Name: Address License Number City State Zip Code Tax ID Number Guardian Broker Code Guardian Agency Agency Code Fax Phone Number Commissions: Split % Pay to Broker Pay to Agency Dental Standard M Scale Percent % Page 3

9 And its Affiliates and Subsidiaries Midwest Regional Office P.O. Box 8012 Appleton, WI Enrollment/Change Form Page 1 of 3 Please print clearly and mark carefully. Employer Name: PLEASE CHECK APPROPRIATE BOX Initial Enrollment Add Employee/ Dependents Drop/Refuse Coverage Group Plan Number: Benefits Effective: Informationn Change Family Status Change Class: About You: First, MI, Last Name: Address/City/State/Zip: Division: (Please obtain this from your Employer) Social Security Number - - Gender: M F Date of Birth (mm-dd-yy): - - Phone: ( ) - Address: Are you married or do you have a spouse? Do you have children or other dependents? Yes Yes No No Date of marriage/union: - - Placement date of adopted child: About Your Job: Work Status: Active Retired Hours worked per week: Job Title: Date of full time hire: Cobra/State Continuation - - About Your Family: Please include the names of the dependents you wish to enroll for coverage. A dependent is a person that you, as a taxpayer, claim; who relies on you for financial support; and for whom you qualify for a dependency tax exception. Dependency tax exemptions are subject to IRS rules and regulations. Additional information may be required for non-standard dependents such as a grandchild, a niece or a nephew. Spouse (First, MI, Last Name) Child/ Dependent 1: Add Drop Gender Date of Birth M - - F Gender Date of Birth M - - F h (mm-dd-yyyy) h (mm-dd-yyyy) Status (check all that apply) Student (post high school) Non standardd dependent Disabled Child/ Dependent 2: Add Drop Gender Date of Birth M - - F h (mm-dd-yyyy) Status (check all that apply) Student (post high school) Non standardd dependent Disabled Child/ Dependent 3: Add Drop Gender Date of Birth M - - F h (mm-dd-yyyy) Status (check all that apply) Student (post high school) Non standardd dependent Disabled Child/ Dependent 4: Add Drop Gender Date of Birth M - - F h (mm-dd-yyyy) Status (check all that apply) Student (post high school) Non standardd dependent Disabled P CEF2012 Questions? Call the Guardian Helplinee (888) GG SGS-MRO (2/13)

10 Page 2 of 3 Dental Coverage: PPO* You must be enrolled to cover your dependents. Check only one box. Employee Only EE & Spouse EE & Dependent/Child(ren) EE, Spouse & Dependent/Child(ren) *Monthly rate (includes Pediatric Essential Health Benefit) I do not want this coverage. If you do not want Dental Coverage, please mark all that apply: I am covered under another Dental plan. My spouse is covered under another Dental plan. My dependents are covered under another Dental plan. Signature I understand that my dependent(s) cannot be enrolled for a coverage, if I am not enrolled for that coverage. You must be legally working in the United States in order to be eligible for coverage. Underwriting must approve coverage for employees on temporary assignment (a) exceeding 1 year; or (b) in an area under travel warning by the US Department of State, subject to state specific variations. You must be legally working in the United States, or working outside of the United States for a United States based employer in a country or region approved by us. If coverage is waived and you later decide to enroll, late entrant penalties may apply. You may also have to provide, at your own expense, proof of insurability. Guardian has the right to reject your request. I understand that I must be actively at work or my elected coverage will not take effect until I have met the eligibility requirements (as defined in the benefit booklet.) This does not apply to eligible retirees. Plan design limitations and exclusions may apply. For complete details of coverage, please refer to your benefit booklet. State limitations may apply. Your coverage will not be effective until approved by a Guardian underwriter. I hereby apply for the group benefit(s) that I have chosen above. I understand that I must meet eligibility requirements for all coverages that I have chosen above. I agree that my employer may deduct premiums from my pay or add premiums to my dues, if they are required for the coverage I have chosen above. I acknowledge and consent to receiving electronic copies of Guardian coverage related documents, in lieu of paper copies, to the extent permitted by applicable law. I may change this election only by providing Guardian thirty (30) day prior written notice. I attest that the information provided above is true and correct to the best of my knowledge. Any person who with intent to defraud any insurance company or other person files an application for insurance or statements of claim containing any materially, false information, or conceals for purpose of misleading information concerning any fact material hereto, commits a fraudulent insurance act, which is a crime, and may also be subject to civil penalties, or denial of insurance benefits. The state in which you reside may have a specific state fraud warning. Please refer to the attached Fraud Warning Statements page. The laws of New York require the following statement appear: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. (Does not apply to Life Insurance.) SIGNATURE OF EMPLOYEE X DATE CEF2012 Questions? Call the Guardian Helpline (888) GG SGS-MRO (2/13)

11 Page 3 of 3 Fraud Warning Statements The laws of several states require the following statements to appear on the enrollment form. Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Connecticut, Iowa, Kansas, Nebraska, Oregon, and Vermont: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of a fraudulent insurance act, which may be a crime, and may also be subject to civil penalties. Delaware, Indiana and Oklahoma: WARNING: Any person who knowingly, and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Louisiana and Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to fines and confinements in state prison. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment or a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties or denial of insurance benefits. Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefit. Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. 638:20. New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Ohio: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Rhode Island: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CEF2012 Questions? Call the Guardian Helpline (888) GG SGS-MRO (2/13)

12 Northeast Regional Office PO Box Lehigh Valley PA Midwest Regional Office PO Box 8012 Appleton WI Western Regional Office PO Box 2454 Spokane WA Guard-O-Matic Application Instructions: 1. Complete all parts of this form. 2. Remember to indicate the complete name and address of your bank 3. Execute all signatures where indicated. If account requires countersignatures both signatures must appear. 4. IMPORTANT: Attach check marked SAMPLE from your checkbook 5. Existing planholders/policyholders please include plan/policy number and return the original copy of the form to Guardian. Maintain a copy for your records. 6. New planholders/policyholders please complete form and submit the original copy with the application for coverage. Maintain a copy for your records. 7. The Account number is located at the bottom of your check. It is the series of numbers to the right of the second colon. Example: : : The Account number would be The Transit number is the last five numbers prior to the second colon. Example: : : The Transit number would be REQUEST FOR PARTICIPATION IN GUARD-O-MATIC PRE-AUTHORIZED DEBIT PLAN The Guardian Life Insurance Company of America is hereby requested and authorized to initiate debt entries electronically, by paper means or by any other commercially accepted method to be charged against the checking account of: Name of Depositor: (As shown on Bank Records) Account Number: Transit Number: Bank Name: Bank Address: (Bank Where Account is Maintained) It is understood that: 1. Debit entries will be drawn as required to pay premium on the due date. Receipt of the Insurance Statement bearing this due date will be notification of the drawing of debit entries in the exact amount due and then payable. 2. The debit entry on your bank statement will constitute receipts for payment of premium. 3. The privilege of paying premiums under this plan will terminate: (a) At the election of the premium payor, upon at least thirty (30) days notice in writing, to Guardian. Such action will terminate coverage. (b) At the election of the above bank, upon at least thirty (30) days notice in writing, to Guardian and to the undersigned depositor. (c) At the election of Guardian, upon at least thirty (30) days notice in writing, to the planholder/policyholder at the address on record and to the above bank. 4. If a debit entry is refused payment by the bank for any reason, other than an error in drawing, it will be determined that payment of premium was not tendered by the planholder/policyholder and the plan/policy will lapse subject to the grace period provision of the plan. (1) (2) Signature(s) of Depositor(s) Responsible for Premium Payment (As shown on the bank s records) Plan Number: Date: FOR GUARDIAN USE ONLY: Plan/Policy Number: RGO: Sample Check: Bank notified: GO Coded: First Payment: Approved by: Date: GG-414 (5/07) * * * *

13 INDEMNIFICATION AGREEMENT To: Bank Named On Request For Participation in Guard-O-Matic In consideration of your compliance with the request and authorization of the Depositor name on the application. The Guardian Life Insurance Company of America agrees that: 1. It will indemnify and hold you harmless from any loss your may suffer as a consequence of your actions, resulting from or in connection with the execution and issuance of any electronic debit, check, draft or order, whether or not genuine, purported to be drawn on the account of such Depositor by The Guardian Life Insurance Company of America and made payable to its own order or to the order of the Trustees of the Insurance Fund as named on the reverse side and received by you in the regular course of business, for the purpose of payment, including any costs or expenses reasonably incurred in connection therewith. 2. In the event that any such electronic debit, check, draft or order shall be dishonored, whether with or without cause, and whether intentionally or inadvertently, to indemnify you for any loss even though dishonor results in the loss of the insurance. 3. To defend at our own cost and expense any action which might be brought against you by any Depositor or other person because of your actions taken pursuant to the foregoing requests or in any manner arising by reason of your participation in the foregoing plan of premium collection. 4. Your participation in the Plan/Policy or that of the Depositor may be terminated by written notice from either party to the other. Likewise, your participation and that of The Guardian Life Insurance Company of America may be terminated by thirty (30) days written notice from either party to the other. 5. It will refund to you any amount erroneously paid by you to The Guardian Life Insurance Company of America or to the Trustees of the Group Insurance Fund named on the reverse side on any such debit entry it claim for the amount of such erroneous payment is made by you within fifteen months from the date of the debit entry on which such erroneous payment was made. THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA Authorized in a Resolution by the Board of Directors of The Guardian Life Insurance Company of America November 22, 1967 Secretary

14 Guardian Anytime Website Pre-Registration Form & Consent to Delivery of Electronic Materials Use this form to pre-register for the Guardian Anytime Benefits Administration Website. Pre-registration enables you to receive your first bill online and begin using the site to administer your benefits as soon as your plan information has been loaded into Guardian systems. Please include this form with the initial case submission package (enrollments, applications, etc.) If you prefer, you may register for the site yourself, once you receive your first bill. PLAN INFORMATION Company Name Group Number Effective Date Division Number(s): All: Only Division Numbers: PLAN ADMINISTRATOR(S) AUTHORIZED TO ADD, VIEW OR CHANGE ALL INFORMATION VIA GUARDIAN ANYTIME Each individual pre-registered by Guardian will receive an with instructions on how to complete the registration process and access the Guardian Anytime website once your plan information is available. As part of Guardian s efforts to Go Green, billing statements will be available for viewing and, if you choose, payment through Guardian Anytime. If you require paper billing statements mailed to you, please log onto Guardian Anytime and select Change Billing Options under the Billing tab. Administrative fees for paper bills may apply. If you have questions about the pre-registration process, please call the Customer Response Unit at Administrator(s) Names Telephone Number(s) Address(es) ~Please print clearly~ GENERAL CONSENT TO ELECTRONIC DELIVERY OF PLAN MATERIALS Guardian will make all plan materials and related documents available to you online at: By signing below, you affirm that you are an authorized representative of the above referenced Group. Further, you acknowledge your consent to receiving electronic versions of Guardian plan materials and related documents, in lieu of paper copies, to the extent permitted by applicable law. You understand that you may change this election by providing Guardian thirty (30) days prior written notice Name and Title of Authorized Representative Signature, Authorized Representative GG (10/12)