Option 2 and Option 3 of Flexible Choice POS, and Option 1 of Flexible Choice POS.
|
|
- Maurice Webster
- 5 years ago
- Views:
Transcription
1 Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. (KFHP-MAS) 2101 East Jefferson Street Rockville, Maryland Kaiser Permanente Insurance Company (KPIC) One Kaiser Plaza, Oakland, California VIRGINIA MID/LARGE GROUP EMPLOYER APPLICATION APPLICATION is hereby made for group health coverage based upon the following statements and representations: Product* MEDICAL Service delivery options** HMO Signature Select Deductible HMO Signature Select HSA-Qualified Deductible HMO (HDHP) Signature Select CDHC Options (Available if a KP health plan is purchased): KP Administered HSA (available with HDHP only) KP Administered HRA (available with HMO, DHMO, HDHP) KP Administered FSA (available with HMO, DHMO, HDHP) KP Administered HRA/FSA (available with HMO, DHMO, HDHP) Added Choice POS Signature Select Flexible Choice POS Signature Only Out-of-Area PPO DENTALENHANCEMENTS(OPTIONAL) Employer-selected adult dental rider Dental benefits are underwritten by KFHP- MAS *The Service Delivery Options only apply to the benefits underwritten by KFHP-MAS. The Service Delivery Options do not apply to the products underwritten by KPIC. **Benefits underwritten by KFHP-MAS: Benefits underwritten by KPIC: HMO Option 2 and Option 3 of Flexible Choice POS, and Option 1 of Flexible Choice POS. Out-of Area PPO. Added Choice POS DO NOT ALTER THIS DOCUMENT EXCEPT TO FILL IN THE BLANKS AND CHECK THE BOXES PROVIDED. Due to regulatory reuirements, this Application will not be accepted if any other changes are made. Complete this Application in its entirety, in black ink, and sign and return it to your Sales Representative. If you have any uestions concerning the benefits and services that are provided by or excluded under the benefit plan selected, please contact your account manager or sales representative before signing this application. VALG/KFHP-KPIC APP 01/16
2 Section 1 APPLICANT S INFORMATION Purchaser's legal business name Group/Policy ID number: D/B/A (if applicable) Legal Corporation Sole Proprietorship Status Partnership Other Street address City State Zip code Executive contact person: Title Phone Fax Billing address City State Zip code Billing contact person Title Phone Fax Rate address City State Zip code Rate contact person Title Phone Fax Corporate/Home Office address City State Zip code Corporate/Home Office contact person Title Phone Fax Federal tax ID number Primary SIC code Reuested effective date Are there any affiliates or subsidiaries to be covered? If yes, please provider details below Company Name Address Yes No Affiliate Subsidiary Company Name Address Affiliate Subsidiary City, State, Zip City, State, Zip Section 2: EMPLOYEE ELIGIBILITY Live or work within the KFHP-MAS service area Live and work outside of KFHP-MAS service area Total A. Total # of full-time employees working [ ] hours or more per week B. Total # of permanent part-time employees C. Total # of employees reuesting group health coverage D. Total # of employees of all affiliates, subsidiaries and offices VALG/KFHP-KPIC APP 01/16 2
3 Section 3: BILLING INFORMATION Same as applicant information? Yes No If yes, skip to section 4 Billing address City State ZIP code Billing contact person Title Phone Fax For office use only Proration/Eff status F/MB H/DE D/DE SEC Jurisdiction: VA Section 4: RATES Employee Only Employer Contribution % HMO Rate POS Rate Out-of-Area PPO Rate HMO POS Two-Party Employee + Adult Employee + Child Employee + Child(ren) Family Medicare Section 5: OTHER HEALTH CARE COVERAGE INFORMATION Have you ever had prior coverage with KFHP-MAS and/or KPIC? Yes No If yes, under what name? If yes and coverage was provided, what was the Group/Policy ID number? Are you applying for this insurance to replace current or prior coverage provided by another group health carrier? Yes No Carrier's name Group/policy number Effective date Termination date Has an insurance carrier terminated your coverage in the past five years? Yes No If yes, please provide the following: Carrier's name Reason for termination How many group insurance carriers provided coverage to you within the past 3 years? Is your Company exempt from COBRA or any state continuation plan? Yes No If yes, please explain VALG/KFHP-KPIC APP 01/16 3
4 Section 6: BROKER INFORMATION (to be completed for brokered sales only) Broker name Broker firm name Group Number Assigned: Street address City State Zip Phone Fax address Life & Health license number Federal tax ID number General Agent name By signing this Application, Applicant authorizes the individual named above to act as a broker of record for health plan coverage, through KFHP-MAS, and/or KPIC, effective on Signed at Month Day Year City State Month Day Year YOUR BROKER IS/MAY BE PAID COMMISSIONS AND OTHER FINANCIAL INCENTIVES BY KAISER FOUNDATION HEALTH PLAN OF THE MID-ATLANTIC STATES, INC. AND/OR KAISER PERMANENTE INSURANCE COMPANY. Section 7: ENROLLMENT INFORMATION Annual open enrollment period: Enroll during month of for coverage effective 1 st, (year) New employee coverage becomes effective: Note: Maximum waiting period allowed is 90 days from the date of hire. Dependent Coverage Limiting Age for Dependent Children: (Such age may not be less than age 26) Coverage will not be provided to Domestic Partners Coverage will be provided to Domestic Partners VALG/KFHP-KPIC APP 01/16 4
5 Section 8 EMPLOYER AGREEMENT The employer agrees to the following eligibility reuirements: 1)! To meet the following Minimum Participation Reuirement: If the plan is non-contributory, then 100% of the net eligible employees must be enrolled. If the plan is contributory, then 75% of the net eligible employees must be enrolled.! [Net eligible employees = Total eligible employees less employees working less than [! and employees with other health coverage.] 2)! Business Certification ] hours per week We certify that our company has a legitimate business operation, and does not exist for the sole purpose of obtaining health care coverage. In addition, we certify that our company has been actively engaged in our business for at least three months from the date of this Application. 3)! The Applicant agrees that in submitting this Application, it is acting for and on behalf of itself and as the agent and representative of its employees and COBRA participants, if applicable. The Applicant is not the agent or representative of KFHP-MAS or KPIC for any purpose of this Application or any Group Agreement that is issued pursuant to this Application, except enrollment. 4)! The Applicant agrees to offer enrollment in the KFHP-MAS and/or KPIC products to all individuals entitled to coverage on conditions no less favorable than those for any other health care plan available through the Group. 5)! The Applicant agrees that a bona fide employer/employee relationship exists with respect to each subscriber to be enrolled in the KFHP-MAS/KPIC products. This reuirement does not apply to eligible Taft-Hartley trusts and partnerships. 6)! The Applicant agrees that, unless KFHP-MAS and KPIC agree otherwise in writing, all persons to be covered, except retirees, dependents and those former employees covered under a continuation of benefits, are Eligible Employees of the Applicant, or a subsidiary or affiliate listed within this Application. Eligible Employee means an employee who works for a Group employer on a full-time basis, has a normal work week of 30 or more hours, has satisfied applicable waiting period reuirements, and is not a part-time, temporary, seasonal or substitute employee or independent contractor who receives a 1099 statement. Employee as the meaning given such term under section 3(6) or the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1002(6)). Independent contractors/1099 employees are not eligible for coverage. 7)! The Applicant agrees that it assumes responsibility for, and all liability related to, its determinations regarding the eligibility status of each Eligible Employee and his/her Dependents, and understands that KFHP-MAS and KPIC will rely on such eligibility determinations in effectuating coverage. Furthermore, the Applicant agrees it will be financially liable to KFHP-MAS and/or KPIC for any errors and/or omissions. 8)! The Applicant agrees that as reuired by state law, employer group has a worker's compensation coverage for its employees. The Group carries workers compensation insurance. The Group does not carry workers compensation insurance. If your company does not carry workers compensation coverage, please explain. 9)! The Applicant agrees to hold an open enrollment period at least once a year, during which all individuals entitled to coverage are offered a choice of enrollment in the KFHP-MAS/KPIC products. 10)!The Applicant agrees that the Group coverage applied for in this application will not become effective until: a) This application is approved by KFHP-MAS and/or KPIC; and b) An advance payment eual to an estimated one-month premium is received by KFHP-MAS and/or KPIC; and c) That if the cost of the coverage is to be contributory, the reuired percentage of the eligible employees shall have agreed to make the reuired contribution. 11) The Applicant agrees that the agent or the broker do not have the power on behalf of KFHP-MAS and/or KPIC, to make or modify any application for coverage, to make any promise or representation, or to waive any of the companies' (KFHP-MAS/KPIC) rights or reuirements. WARNING: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE VIOLATED THE STATE LAW. VALG/KFHP-KPIC APP 01/16 5
6 POINT-OF-SERVICE (POS) OPTION DISCLOSURE STATEMENT FOR APPLICANTS FROM THE COMMONWEALTH OF VIRGINIA: Group Number Assigned: Under the law of the Commonwealth of Virginia, your employees may purchase a point-of-service option as an additional benefit. A point-of-service option allows your employees to obtain covered health care services from physicians and other providers outside of the KFHP-MAS HMO network. KFHP-MAS offers a POS plan (Added Choice) and, in conjunction with KPIC, Kaiser Permanente Flexible Choice to meet this statutory reuirement. You have the choice to pay the entire cost of the point-of-service options, pay a percentage of the cost of these options or reuire your employees to pay the entire cost of these options. The cost of the point-of-service options is identified in your proposal. Each eligible Employee must indicate his/her selection of the mandatory point-of-service option. Failure to do so will result in HMO coverage only. Applicant must provide KFHP-MAS with a list of those eligible Employees who have chosen the point-of-service option. By signing this Application, Applicant certifies that it has read and understands this disclosure statement. Applicant further certifies that it has provided notice of availability of these additional benefits to its eligible employees. Section 9 GROUP ACKNOWLEDGEMENT I understand and agree, on behalf of the employer, that the statements in this application and the answers to the Underwriting Questionnaire, if attached, are true and complete to the best of my knowledge and belief. I understand and agree that such statements and answers; a) will become part of any Group Agreement which may ultimately be issued by KFHP-MAS; (b) will become part of any policy or policies which may ultimately be issued by KPIC; and c) are made to induce KPIC and/or KFHP-MAS, to issue the group coverage as applied for. I have the authority to make the statements and representations contained in this Application and to execute this Application on behalf of the Group. WARNING: ANY PERSON WHO, WITH THE INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY HAVE VIOLATED THE STATE LAW. Signed at on City State Month Day Year By (full name in print) Signature Title Section 10 ADDITIONAL NOTES VALG/KFHP-KPIC APP 01/16 6
7 For KFHP - MAS Use Only Group Number Assigned Delivery System Signature Select OAD/OAS Average Age Initial Contract Period Begin Initial Contract Period End Jurisdiction: Plan Riders: DME P&O Infertility Hearing Aids CAM Pharmacy Carve Out Adult Dental Pediatric Dental Sales Representative (Print Name) BENEFITS HMO POS OOA Step Type Plan Type Rx Dental Copayment Coinsurance Deductible Out-of-Pocket Maximum Carve Out (Circle) Rx Chiro None STEPS Employee Two-Party Employee + Adult Employee + Child Employee + Children Family Employer Contribution % HMO POS HMO Rate POS Rate Out-of-Area PPO Rate VALG/KFHP-KPIC APP 01/16 7
DENTALENHANCEMENTS(OPTIONAL) Service deliveryoptions** HMO q Signature q Select Deductible HMO q Signature q Select.
Kaiser Foundation Health Plan of the Mid- Atlantic States, Inc. (KFHP-MAS) 2101 East Jefferson Street Rockville, Maryland 20852 Kaiser Permanente Insurance Company (KPIC) One Kaiser Plaza Oakland, California
More informationPLAN ADD/CHANGE REQUEST Fax to
Fax to Kaiser Permanente at 800-369-8010 or to your broker. You can use this form to: Discontinue one or more of your current medical plans. Add additional medical plan(s). Discontinue your current dental
More informationMinnesota Group Application - Small Employer
Minnesota Group Application - Small Employer Submission Information Group submissions do not begin processing until all the information in the checklist below is included. Submissions received after the
More informationMinnesota Group Application - Small Employer
Minnesota Group Application - Small Employer Submission Information Group submissions do not begin processing until all the information in the checklist below is included. Submissions received after the
More informationStreet Address (P.O. Box not acceptable) City State ZIP. Billing Address (if different than above) City State ZIP
California Small Group Business Employer Application FOR GROUP COVERAGE (2-50 ELIGIBLE EMPLOYEES) TO COMPLY WITH CALIFORNIA LAW WHEREVER THE TERM "SPOUSE" APPEARS IT SHALL BE CONSTRUED TO INCLUDE DOMESTIC
More informationSmall Business Guidelines
The following policy and qualification guidelines apply to all employers offering Kaiser Permanente small business coverage. ELIGIBILITY You may be eligible for Kaiser Permanente s guaranteed issue and
More informationMinnesota Group Application - Small Employer
Minnesota Group Application - Small Employer Submission Information Group submissions do not begin processing until all the information in the checklist below is included. Submissions received after the
More informationMinnesota Group Application - Small Employer
Minnesota Group Application - Small Employer Submission Information Group submissions do not begin processing until all the information in the checklist below is included. Submissions received after the
More informationOregon Small Group Application
Oregon Small Group Application Health Net Health Plan of Oregon, Inc. (1 50 employees) Subscriber group information Full legal name of employer (include punctuation and abbreviations) hereafter known as
More informationMINNESOTA GROUP APPLICATION SMALL GROUP
Employer eligibility information Today s Date: Requested Eff. Date: HealthPartners Sales Executive: Full Legal Group Name: DBA (if applicable): Address: City, State, Zip: County: Phone: Fax: Federal Tax
More informationPennsylvania Employer Application
Pennsylvania Employer Application FOR GROUP COVERAGE (100 or fewer eligible employees) Life, Accidental Death & Dismemberment, Disability, Aetna PPO and Aetna Indemnity plans are underwritten by Aetna
More informationSmall Business Master Group Application Blue Shield of California and Blue Shield of California Life & Health Insurance Company
Small Business Master Group Application Blue Shield of California and Blue Shield of California Life & Health Insurance Company Effective April 1, 2016 Section 1 Company Information Please type or print
More informationMINNESOTA GROUP APPLICATION SMALL GROUP
EMPLOYER ELIGIBILITY INFORMATION Today s Date: Requested Eff. Date: HealthPartners Sales Executive: Full Legal Group Name: DBA (if applicable): Address: City, State, Zip: County: Phone: Fax: Federal Tax
More informationCalifornia Small Group Business Employer Application
California Small Group Business Employer Application TO COMPLY WITH CALIFORNIA LAW WHEREVER THE TERM "SPOUSE" APPEARS IT SHALL BE CONSTRUED TO INCLUDE DOMESTIC PARTNER. FOR GROUP COVERAGE (2-50 ELIGIBLE
More informationCareFirst BlueChoice, Inc.
CareFirst BlueChoice, Inc. 840 First Street, NE Washington, DC 20065 202-479-8000 An independent licensee of the Blue Cross and Blue Shield Association GROUP CONTRACT APPLICATION If this Application is
More informationOklahoma Employer Application
Oklahoma Employer Application FOR GROUP COVERAGE (51-100 ELIGIBLE EMPLOYEES) Life, Accidental Death & Personal Loss, Disability, Aetna Open Access MC Plans, Aetna Choice Plan PPO, Aetna Savings Plus Plan
More informationSECTION A - Employer Information 1. Company Name: Full legal name of Company Doing business as (dba): 2. Employer address: Street
Employer Stop-loss Implementation Questionnaire National General Benefits Solutions Self-Funded Program Instructions for completing this agreement: 1) The employer or employer representative must complete
More informationBlue Shield of California Blue Shield of California Life & Health Insurance Company Small Group Underwriting Guidelines for Producers
Blue Shield of California Blue Shield of California Life & Health Insurance Company Small Group Underwriting Guidelines for Producers Effective October 1, 2010 Groups of 2 to 50 eligible employees This
More informationPlan highlights and rates. Effective January to June 2011
Plan highlights and rates Effective January to June 2011 2011 Small Business RATE AREA 4 Contents 2 3 4 5 6 7 8 9 10 11 12 13 14 15 17 Copayment plans Predictable out-of-pocket costs and no annual deductible
More informationEmployer Group Application (Small Group 1-100)
Employer Group Application (Small Group 1-100) TEXAS Humana.com You have the option to choose the Consumer Choice HMO Benefits Health Plan or the Consumer Choice POS Benefits Health Plan that, either in
More informationLarge Business Application
Large Business Application for Group Service Agreement/Group Policy Medical and Life/AD&D plans are provided by Health Net of California, Inc. and/or Health Net Life Insurance Company (together, Health
More informationOregon Employer Groups Large Group Application
Oregon Employer Groups Large Group Application (51+ employees) Subscriber Group information Full legal name of employer hereafter known as Subscriber Group (include punctuation and abbreviations): Group
More informationCommercial Underwriting Package
Commercial Underwriting Package Commercial health insurance coverage is available to employer, trust and association groups, subscribers and dependents that meet the qualifications specified in 4235 (c)
More informationSMALL GROUP PLAN (1-100) EMPLOYER HEALTH CARE COVERAGE APPLICATION SUTTER HEALTH PLUS
SMALL GROUP PLAN (1-100) EMPLOYER HEALTH CARE COVERAGE APPLICATION SUTTER HEALTH PLUS! Language Assistance If you have questions about completing this application (in English or another language), please
More information2016 Application for Small Employer Coverage
2016 Application for Small Employer Coverage Instructions: Thank you for applying for coverage from Independence Blue Cross. Follow the instructions below to complete your application. 1. Carefully review
More informationTIME INSURANCE COMPANY EMPLOYER STOP LOSS APPLICATION for Assurant Self-Funded Program
TIME INSURANCE COMPANY EMPLOYER STOP LOSS APPLICATION for Assurant Self-Funded Program Instructions for completing this agreement: 1) The employer or employer representative must complete the entire Application
More informationPlan highlights and rates
Plan highlights and rates Effective January to June 2010 2010 Small Business Rate area 7 welcome to kaiser permanente On these pages, you ll find an overview of available plan benefits for small businesses.
More informationPlan highlights and rates
Plan highlights and rates Effective January to June 2010 2010 Small Business Rate area 5 welcome to kaiser permanente On these pages, you ll find an overview of available plan benefits for small businesses.
More informationEmployer Group Enrollment Application/ Participation Agreement/Change Form
Employer Group Enrollment Application/ Participation Agreement/Change Form initial enrollment change 1. Group/Company Information Business Name Has this business ever been known by another name? o Yes
More informationNew York Small Group Employee Enrollment Application For Groups of (Medical/Vision) For Groups of 1 50 (Dental)
New York Small Employee Enrollment Application For s of 1 100 1 (Medical/Vision) For s of 1 50 () You, the employee, must complete this application. You are solely responsible for its accuracy and completeness.
More informationMaster Group Application (for 1 to 50 eligible employees) Blue Shield of California
Master Group Application (for 1 to 50 eligible employees) Blue Shield of California Effective January 1, 2014 Section 1 Company Information Please type or print clearly in black ink. 1 Full legal business
More informationUnderwriting guidelines for brokers and producers
KAISER PERMANENTE FOR SMALL BUSINESS, CALIFORNIA Underwriting guidelines for brokers and producers Kaiser Foundation Health Plan, Inc. Kaiser Permanente Insurance Company For businesses with 1 to 100 employees
More informationApplication for Group Coverage
Application for Group Coverage Instructions: Thank you for applying for coverage from Independence Blue Cross (IBC). Follow the instructions below to complete your application. 1. Carefully review and
More informationCommercial Underwriting Package
Commercial Underwriting Package Commercial health insurance coverage is available to employer, trust and association groups, subscribers and dependents that meet the qualifications specified in 4235 (c)
More informationFull legal name of Company. City County State Zip Mailing address: (If different) Street City State Zip
Employer Stop-loss Implementation Questionnaire National General Benefits Solutions Self-Funded Program Instructions for completing this agreement: 1) The employer or employer representative must complete
More informationNew York Community-Rated Small Group (2-50) Application OHP
New York Community-Rated Small Group (2-50) Application OHP Oxford Health Plans (NY), Inc. Oxford Health Insurance Inc. www.oxfordhealth.com Mailing Address: Group Enrollment Department, 14 Central Park
More information2018 Application for Small Employer Coverage
2018 Application for Small Employer Coverage Instructions: Thank you for applying for coverage from Independence Blue Cross. Follow the instructions below to complete your application. 1. Carefully review
More informationNew York Small Group Application OHI I. GENERAL INFORMATION
New York Small Group Application OHI Oxford Health Insurance Inc. www.oxfordhealth.com Mailing Address: Group Enrollment Department, 14 Central Park Drive, Hooksett, NH 03106 I. GENERAL INFORMATION Freedom
More informationEmployer Enrollment Application For Employee Small Groups California
Employer Enrollment Application For 1-100 Employee Small Groups California Health care plans offered by Anthem Blue Cross (Anthem). Insurance plans offered by Anthem Blue Cross Life and Health Insurance
More informationInstructions for completing the Kaiser Permanente for Individuals and Families Application for Health Coverage
Child Health Program / Community Health Care Program Instructions for completing the Kaiser Permanente for Individuals and Families Application for Health Coverage This document tells you how to complete
More informationSMALL GROUP EMPLOYER APPLICATION
SMALL GROUP EMPLOYER APPLICATION INTERNAL USE ONLY GROUP NO. UNDERWRITER NO. EFFECTIVE DATE *For HMO products, You have the option to choose the Consumer Choice of Benefits Health Maintenance Organization
More informationIllinois Standard Health Employee Application for Small Employers
Illinois Standard Health Employee Application for Small Employers INSURER USE ONLY Policy/Group No. Section No. Effective Date New Hire Waiting Period For assistance in completing this application, please
More informationConnecticut Small Group Blue Ribbon Application Oxford Health Insurance, Inc.
Connecticut Small Group Blue Ribbon Application Oxford Health Insurance, Inc. Mailing Address: P.O. Box 29142, Hot Springs, AR 71903 800-889-7658 www.oxfordhealth.com I. general information 1. Full legal
More informationNew York Small Group Application OHI I. GENERAL INFORMATION PPO PPO HSA EPO EPO HSA
New York Small Group Application OHI Oxford Health Insurance Inc. www.oxfordhealth.com Mailing Address: Group Enrollment Department, 14 Central Park Drive, Hooksett, NH 03106 I. GENERAL INFORMATION PPO
More informationNew York Small Group Application OHI I. GENERAL INFORMATION PPO PPO HSA EPO EPO HSA
New York Small Group Application OHI Oxford Health Insurance Inc. www.oxfordhealth.com Mailing Address: Group Enrollment Department, 14 Central Park Drive, Hooksett, NH 03106 I. GENERAL INFORMATION PPO
More informationNo carve outs allowed after 1/1/14. Current carve out groups written prior to 1/1/14 will not. automatically nonrenewing
Age Band or Composite: Carve Out Criteria: Employer Eligibility: Only age band rates available. Composite rates are not available for groups of 2 to 50 lives. No carve outs allowed except for union vs.
More informationNew Jersey Large Employer Application - OHP
Freedom Plan Liberty Plan SM Primary Advantage (Freedom & Liberty) New Jersey Large Employer Application - OHP Oxford Health Plans (NJ), Inc. Mailing Address: 4 Research Drive, Shelton, CT 06484 www.oxfordhealth.com
More informationEmployer Enrollment Application For Employee Small Groups California
Employer Enrollment Application For 1-100 Employee Small Groups California Health care plans offered by Anthem Blue Cross (Anthem). Insurance plans offered by Anthem Blue Cross Life and Health Insurance
More informationPlease Send Correspondence To: Answered all applicable questions? P.O. Box 19032, Green Bay, WI Selected a method of payment?
Employer Application Alternate Funding Employer Data Employer Tax ID No. All Savers Have you: Signed all forms necessary for health plan application? Please Send Correspondence To: Answered all applicable
More informationCheck Plan Type: Check Enrollment Type: Fill Out Sections: q KP/HSA Small Group Employee Enrollment Form q Multi-Choice
Kaiser Foundation Health Plan of Georgia, Inc. Kaiser Permanente Insurance Company (KPIC) Check Plan Type: Check Enrollment Type: Fill Out Sections: q KP/HSA q New Hire A, B, C, D q Added Choice/HSA Added
More informationGroup Size: mid-size Acct. Code: Group Number(s): Street Address: For Internal Use Only City: Zip: City/County: Group Administrator: Title:
Anthem Blue Cross and Blue Shield HealthKeepers, Inc. Group Size: 51-99 mid-size Acct. Code: Group Number(s): Company Name ( the Applicant ): Year Operational: Street Address: For Internal Use Only City:
More informationNew Group Checklist. 30 days prior to the effective date, the following Group information is required:
New Group Checklist 30 days prior to the effective date, the following Group information is required: Group Policy Application completed and signed. Enrollment forms; be sure to complete any applicable
More informationIllinois Employer Application and Joinder Agreement
Illinois Employer Application and Joinder Agreement FOR GROUP COVERAGE (2 50 EMPLOYEES) Life, Accidental Death & Personal Loss Coverage (AD&D Ultra ), Disability, Aetna Vision SM Preferred plans, and Aetna
More informationMEDICAL UNDERWRITING GUIDELINES LARGE GROUP
MEDICAL UNDERWRITING GUIDELINES LARGE GROUP This comparison reflects the general guidelines set by a carrier. Guidelines may vary depending on group demographics and carrier approval. Product Networks
More informationLehigh Valley Group Application
Lehigh Valley Group Application Oxford Health Insurance, Inc. Mailing Address: 700 East Gate Drive, Suite 103, Mount. Laurel, NJ 08054 www.oxfordhealth.com I. G E N E R A L I N F O R M A T I O N 1. Please
More informationNew York Member Enrollment Form OHI MAILING ADDRESS: P. O. Box 29142, Hot Springs, AR
New York Member Enrollment Form OHI MAILING ADDRESS: P. O. Box 29142, Hot Springs, AR 71903 1-800-444-6222 www.oxfordhealth.com THANK YOU FOR CHOOSING AN OXFORD PRODUCT FOR YOU AND YOUR FAMILY. IMPORTANT:
More informationNew York Large Group Application OHI Oxford Health Insurance Inc. Corporate Address: 4 Research Drive, Shelton, CT
I. GENERAL INFORMATION 1. Full legal name of firm: 2. Address of firm: (Street Address City, State, Zip Code) 3. Plan Administrator/Contact: a. Name b. Title c. Address (If it differs from address of firm)
More information2019 Application for Small Employer Coverage
2019 Application for Small Employer Coverage Instructions: Thank you for applying for coverage from Independence Blue Cross. Follow the instructions below to complete your application. 1. Carefully review
More informationConnecticut Small Group Blue Ribbon Application
Connecticut Small Group Blue Ribbon Application Oxford Health Insurance, Inc. Mailing Address: P.O. Box 7085, Bridgeport, CT 06601-7085 800-889-7658 www.oxfordhealth.com I. G E N E R A L I N F O R M A
More informationPlease complete in blue or black ink only. Section A: Company Information Employer tax ID no. (required) City County State ZIP code
Employer Enrollment Application For 2 50 Employee Small Groups Georgia The purpose of this form is for Blue Cross and Blue Shield of Georgia, Inc. (BCBSGa) and Blue Cross Blue Shield Healthcare Plan of
More informationTRUSTMARK LIFE INSURANCE COMPANY Application for Stop Loss and Ancillary Insurance Coverage
Underwritten by TRUSTMARK LIFE INSURANCE COMPANY Application for Stop Loss and Ancillary Insurance Coverage Application is hereby made to Trustmark Life Insurance Company ( Company ) for Aggregate and
More informationIllinois Small Business Employer Application
Illinois Small Business Employer Application For Groups with 2-50 Eligible Employees SG ER APP IL 3/02 New Group Checklist 2-50 Eligible Employees Thank you for your new group submission. The following
More informationHealthfirst Insurance Company, Inc. Small Group Employer Enrollment Form FTE Employees
Healthfirst Insurance Company, Inc. Small Group Employer Enrollment Form 1 100 FTE Employees Mailing Address: Healthfirst Insurance Company, Inc., Commercial Sales, 100 Church Street, New York, NY 10007
More informationNew Jersey Large Employer Application - OHI Oxford Health Insurance, Inc. Mailing Address: 4 Research Drive, Shelton, CT
New Jersey Large Employer Application - OHI Oxford Health Insurance, Inc. Mailing Address: 4 Research Drive, Shelton, CT 06484 www.oxfordhealth.com I.. GENERAL INFORMATION 1. Full legal name of firm: 2.
More informationCalifornia Small Group Business Employer Application
California Small Group Business Employer Application FOR GROUP COVERAGE (1-100 EMPLOYEES) PENDING REGULATORY APPROVAL TO COMPLY WITH CALIFORNIA LAW, WHEREVER THE TERM "SPOUSE" APPEARS IT SHALL BE CONSTRUED
More informationNew York HMO Small Group (2-50) Application OHP
HMO/Liberty Network New York HMO Small Group (2-50) Application OHP Oxford Health Plans (NY), Inc. www.oxfordhealth.com Mailing Address: Group Enrollment Department, 14 Central Park Drive, Hooksett, NH
More informationPlease fill out in black ink only. Section A: Company Information Employer tax ID no. (required) City County State ZIP code
Employer Enrollment Application For 1-50 Employee Small Groups 1 New Hampshire Please fill out in black ink only. Section A: Company Information Company name Employer tax ID no. (required) Company street
More informationPlease print clearly and fill in each applicable circle. Proposed effective date: / / Enrollment Information
Group Employee and Individual Application and Enrollment Form - 1-100 Employees Visit us at Humana.com Arizona The offering company(ies) listed below, severally or collectively, as the content may require,
More informationUnderwriting guidelines for brokers and producers
KAISER PERMANENTE FOR SMALL BUSINESS CALIFORNIA Underwriting guidelines for brokers and producers Kaiser Foundation Health Plan, Inc. Kaiser Permanente Insurance Company For businesses with 1 to 100 employees
More informationPlease fill out in blue or black ink only. Section A: Employee Information Last name First name M.I. Social Security no.
Employee Enrollment Form For Small s New Hampshire You, the employee, must fill out this enrollment form. You must be sure that all the information is correct and that you fill out all the sections that
More informationBlue Shield of California Blue Shield of California Life & Health Insurance Company Small group underwriting guidelines for producers
Blue Shield of California Blue Shield of California Life & Health Insurance Company Small group underwriting guidelines for producers Effective July 1, 2012 Groups of 2 to 50 eligible employees This booklet
More informationEmployeeElect for 2-50 Member Small Groups
EmployeeElect for 2-50 Member Small Groups Small Group Health Coverage offered by Blue Cross of California (BCC) and BC Life & Health Insurance Company (BCL&H) www.bluecrossca.com Employer Application
More informationPlease fill out in blue or black ink only. Section A: Employee Information Last name First name M.I. Social Security no.
Employee Enrollment Form For 1-50 Employee Small s 1 New Hampshire You, the employee, must fill out this enrollment form. You must be sure that all the information is correct and that you fill out all
More informationConnecticut Small Group Application OHP Oxford Health Plans (CT), Inc.
Connecticut Small Group Application OHP Oxford Health Plans (CT), Inc. Mailing Address: www.oxfordhealth.com I. GENERAL INFORMATION Oxford Gated HMO Oxford Non-Gated HMO Oxford Non-Gated HMO HSA Primary
More informationTRUSTMARK LIFE INSURANCE COMPANY Application for Stop Loss Insurance Coverage
Underwritten by TRUSTMARK LIFE INSURANCE COMPANY Application for Stop Loss Insurance Coverage Application is hereby made to Trustmark Life Insurance Company ( Company ) for Aggregate and Specific Stop
More information( ) If child custody*, enter. Reason for adding/cancelling spouse: date of adoption: *Attach copy of legal documentation
www.calchoice.com A Check here if changes are to be effective at Renewal Complete steps A through E as applicable Complete Employee Information Change Request Form Use blue or black ink pen Do not shrink
More informationMaster group application Blue Shield of California and Blue Shield of California Life & Health Insurance Company
Master group application Blue Shield of California and Blue Shield of California Life & Health Insurance Company For 2 to 50 eligible employees Effective January 1, 2011 Get on the fast track This handy
More informationENROLLMENT WORKSHEET. True Life Destinations 4410 Claiborne Sq E # 334 Hampton, Virginia Employee Name: Employee Benefits Worksheet
True Life Destinations 4410 Claiborne Sq E # 334 Hampton, Virginia 23666 ENROLLMENT WORKSHEET Employee Name: Employee Benefits Worksheet This enrollment worksheet outlines the optioins available to you
More informationHumana Employee Enrollment Application Employees
Humana Employee Enrollment Application - 51-99 Employees The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as Humana. PPO
More informationHumana Employer Group Plan Enrollment Instructions. This is easier than it looks, most pages do not need to be complete - just follow the directions.
Humana Employer Group Plan Enrollment Instructions This is easier than it looks, most pages do not need to be complete - just follow the directions. 1. Employer Application Complete page 1, section 1 only
More informationINDIVIDUAL POLICY CHANGE APPLICATION
INDIVIDUAL POLICY CHANGE APPLICATION Instructions: Please complete all applicable areas of this application. Please print using black ink. WPS/Delta Dental of Wisconsin/WPS Health Plan, Inc. d/b/a Arise
More informationCalifornia Employer Enrollment Application For Small Groups Medical, Dental, Vision, Life and Disability
California Employer Enrollment Application For Small Groups Medical, Dental, Vision, Life and Disability Health care plans offered by Anthem Blue Cross (Anthem). Insurance plans offered by Anthem Blue
More informationSmall Business Employee Enrollment Form Blue Shield of California and Blue Shield of California Life & Health Insurance Company
Small Business Employee Enrollment Form Blue Shield of California and Blue Shield of California Life & Health Insurance Company Effective January 1, 2016 Subscriber information Please note: Missing information
More informationNew York Small Group Employer Enrollment Application For Groups of 1 50*
New York Small Group Employer Enrollment Application For Groups of 1 50* Please complete in blue or black ink only. Section A: Company Information Company name Employer tax ID no. (required) Doing business
More information2009 HMO, Multi-Choice, and HSA-Qualified Deductible HMO Plans
SMALL GROUP PLAN SUMMARIES 2009 HMO, Multi-Choice, and HSA-Qualified Deductible HMO Plans Kaiser Permanente ranked Highest Member Satisfaction among Commercial Health Plans in the South Atlantic Region.
More informationEmployer Group Application (all group sizes)
Employer Group Application (all group sizes) WISCONSIN Humana.com The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this Employer Group Application
More informationLIBERTY UNION FULLY FUNDED HSA PLANS EMPLOYER APPLICATION. by LIFE ASSURANCE COMPANY
LIBERTY UNION FULLY FUNDED HSA PLANS EMPLOYER APPLICATION by LIFE ASSURANCE COMPANY Patient Protection & Affordable Care Act Certified Health Plans for Businesses with up to100 Employees FULLY FUNDED EMPLOYER
More informationHRA Frequently Asked Questions
HRA Frequently Asked Questions HRA Descriptions What is an HRA? How does it work? A health reimbursement arrangement (HRA) is an employer-provided tax-sheltered arrangement that allows individuals to pay
More informationNew Business New Hire New Renewal New COBRA Qualifying/Triggering Event. Address. Spouse/Domestic Partner Child 1 Child 2 Child 3
721 South Parker, Suite 200, Orange, CA 92868 (800) 558-8003 www.calchoice.com / / Life / Enrollment Application Select one A Personal Information Company Name COMPLETE WAIVER SECTION ON PAGE 4 IF YOU
More informationSmall Business Solutions Underwriting Guidelines
Small Business Solutions Underwriting Guidelines Oklahoma FOR BUSINESSES WITH 2 50 ELIGIBLE EMPLOYEES Choice. Simplicity. Affordability. 14.02.018.1-OK (6/05) Oklahoma Underwriting Guidelines Note: State
More informationDental Select Enrollment Kit
Dental Select Enrollment Kit General Info Producer: Phone: Group Name: Email: Fax: Effective: Submission Checklist document/item doc # revised Group Application APP.01.9000286 2017-06 Original proposal
More informationEMPLOYER GROUP ENROLLMENT APPLICATION
EMPLOYER GROUP ENROLLMENT APPLICATION INSTRUCTIONS: Please complete the entire application. Please print using black ink. Section 1 Employer Demographics Type of Application: q New Group q Change to Existing
More informationEmployee last name Employee first name M.I. Employee Social Security no.* (required)
Employee Form For 1 100 Employee Small Groups California Instructions: If you are cancelling coverage for a dependent or changing a name, please provide a reason in the designated sections. Complete electronically,
More informationApplication for Group Insurance Kansas City Life Insurance Company 3520 Broadway Kansas City, MO 64111
Application for Group Insurance Kansas City Life Insurance Company 3520 Broadway Kansas City, MO 64111 Legal Name of Applicant (Policyholder) Federal Tax ID No. Nature of Business Standard Industrial Classification
More informationCoPower ONE Employer Application
CoPower ONE Employer Application Group Information Street Address: DBA: State: Zip: What is your communication preference? Mail E-mail Fax Billing Address (if different): State: Zip: Employer is a: Partnership
More informationSMALL GROUP PLAN Employer Health Care Coverage Application
SMALL GROUP PLAN Employer Health Care Coverage Application Enrollment This application is part of the Group Subscriber Contract, which includes the Evidence of Coverage and Disclosure Form (EOC). By signing
More informationNew Group Checklist. 30 days prior to the effective date, the following Group information is required:
New Group Checklist 30 days prior to the effective date, the following Group information is required: Group Policy Application completed and signed. Enrollment forms; be sure to complete any applicable
More informationSend white copy to: Blue Cross Blue Shield of Massachusetts P.O. Box 9145 North Quincy, MA
F PRINTED BY STANDARD REGISTER U.S.A. ZIPSET Thank you for choosing a Cross Shield plan. Please take a few minutes to help us set up your membership by filling out the attached enrollment form. Before
More informationTRUSTMARK LIFE INSURANCE COMPANY Application for Insurance Coverage
Underwritten by Employer Information FULL LEGAL NAME OF EMPLOYER TRUSTMARK LIFE INSURANCE COMPANY Application for Insurance Coverage Application is hereby made to Trustmark Life Insurance Company ( Company
More informationNew Jersey Large Employer Application - OHI
New Jersey Large Employer Application - OHI Oxford Health Insurance, Inc. Mailing Address: 48 Monroe Turnpike, Trumbull, CT 06611 www.oxfordhealth.com I. G E N E R A L I N F O R M A T I O N Freedom Plan
More information