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) (1) of the New York State Insurance Law and the Underwriting Guidelines of Excellus Health Plan, Inc, doing business as Univera Healthcare ( Health Plan ). The attached documents must be completed by an Employer enrolling in the Health Plan s insurance. Last Revised: August 13, 2014
Please answer questions using blue or black ink, in capital letters staying within the provided boxes. Group Information Form Failure to respond may result in your policy being canceled. SECTION ONE GENERAL GROUP INFO 1. Group/Business name or DBA name (if applicable): 2. Legal entity name, if different than group name: 3. List owner(s) / partner(s): 4. List any commonly owned businesses (if applicable): 5. Tax Identification Number (EIN/TIN): 6. Group Number: Most group health plans are governed by ERISA with the exception of some religious organizations and government entities. If you are not governed by ERISA, please indicate: *Note: For more information about ERISA, please visit http://www.dol.gov/compliance/laws/comp-erisa.htm 7. Business physical address: Street Address: City: State: Zip: County: 8. Address of company headquarters (if different than physical address): Street Address: City: State: Zip: County: 9. Type of group sponsor (check one): Employer: Union: Trustees of Fund: Association: Other: 10. Organization type (check one): Private Corporation: Private Non-Incorporated: Nonprofit: Local Gov t: State Gov t: Church Group: Publicly Traded Organization: Trust: Other: 11. Does your company obtain health insurance coverage through a chamber / trust / association? Yes No C/T/A Name: 12. Indicate if company is organized as a: Parent: Subsidiary: Local Plant / Office / Division: Stand Alone: If applicable, provide related company info below: Company name: EIN/TIN: # Eligible: City: State: Zip: County: 13. How many hours per week must an employee work to be eligible for insurance? 14. Are the owners and their spouses the only people eligible for coverage? Yes No 15. Is there a group medical plan in place in addition to the products offered through Univera Healthcare? New York State of Health Other None If so, what is the type of plan(s)? (ie: HMO, PPO, HDHP, etc) Number of individuals enrolled in this plan 1
Group Information Form Failure to respond may result in your policy being canceled. SECTION TWO REGULATORY EMPLOYER GROUP INFO 1. Number of owners and employees at all locations (all full time and part time employees): Avg. number for prior year Total number currently 2. Did you employ 20 or more employees who worked at least 20 weeks in the current year or prior year? Yes No 3. Do you employ any individuals enrolled in a union sponsored plan? Yes No If yes, please provide the number of such employees 4. Do you employ any Vermont residents who work at employer locations in Vermont, or are telecommuting from their home? Yes No If yes, please provide the number of such employees 5. Do you employ any out-of-state residents who work at out-of-state employer locations other than Vermont? Yes No If yes, please provide the number of such employees SECTION THREE 1. Eligibility Information a) Number of eligible employees and owners, working the minimum number of hours per week** Specific to Univera Healthcare All Other Locations and/or Plans* ELIGIBILITY GROUP INFO b) Number of retirees eligible for the employer group plan (do not count those eligible for Medicare eligible plan) c) Number of individuals enrolled in COBRA/New York continuation of coverage, and/or the young adult option d) Total Eligible (a+b+c) e) Eligible employees declining the group health insurance coverage (i.e. submitted valid waiver) N/A f) Net Eligible (d - e) g) Number of individuals enrolled or electing coverage h) Participation Percentage (g f x 100) 2. This document is being returned via: Email Fax Mail If your company offers a dental and/or Medicare plan through Univera Healthcare, please complete the appropriate supplemental form(s) including the employer contribution for these products. *This portion only to be completed if your company has multiple locations and/or multiple plans. Only include those eligible for health insurance with other insurance carriers that are not eligible to enroll in the Univera Healthcare plan. ** The minimum number hours for groups with 50 and under eligible employees is 20 hours, and 17.5 hours for groups with 51 or more eligible employees. 2
Group Information Form Failure to respond may result in your policy being canceled. Group/Business Name: Instructions: Please enter the percentage of premium contributed by the employer towards the group health insurance. *Note: Be sure to fill out both sections, regardless of whether there are subscribers in each. If your group contributes a flat dollar amount, please calculate the percentage based on the respective section (i.e. Single, Family) premium amount and check the corresponding box. Below are the most commonly used contribution classes. Class Names A001 - All Active Employees A002 - Hourly A003 - Salaried A004 - Management A005 - Non-Management A006 - Union A007 - Non-Union A008 - Full Time A009 - Part-Time Z001 - Custom Class/Other R001 - Retired Non-Medicare Eligible R002 - Retired Medicare Eligible Employer Contribution Range - % (check applicable box for single tier and family tier) Single Family Class Name Product 0% 1-24% 25-49% 50-74% 75-89% 90-100% 0% 1-24% 25-49% 50-74% 75-89% 90-100% Class Name Product 0% 1-24% 25-49% 50-74% 75-89% 90-100% 0% 1-24% 25-49% 50-74% 75-89% 90-100% Class Name Product 0% 1-24% 25-49% 50-74% 75-89% 90-100% 0% 1-24% 25-49% 50-74% 75-89% 90-100% 3
Group Information Form Failure to respond may result in your policy being canceled. Does your group contribute towards an HSA/HRA? Yes No If yes, please complete the section below: Product Type Employer Contribution Towards HSA/HRA Deductible - % Employer Contribution - $ Check One Class Name Product 0% 1-24% 25-49% 50-74% 75-89% 90-100% HSA HSA HRA HRA Check One Class Name Product 0% 1-24% 25-49% 50-74% 75-89% 90-100% HSA HSA HRA HRA Signature: The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete, including the number of persons proposed for coverage who work at least the minimum required hours per week. Employer Authorized Representative Signature Date Phone Number Print Name Email Address 4
Supplemental Form: Dental Failure to respond may result in your policy being canceled. This section is not applicable Group/Business Name: Dental Information Eligibility Information a) Number of eligible employees and owners, working the minimum number of hours per week** b) Number of retirees eligible for the employer group plan c) Number of individuals enrolled in COBRA/New York continuation of coverage, and the young adult option d) Total Eligible (a+b+c) Specific to Univera Healthcare All Other Locations and/or Plans* e) Eligible employees declining the group dental insurance coverage (i.e. submitted valid waiver) N/A f) Net Eligible (d-e) g) Number of individuals enrolled or electing coverage in dental h) Participation Percentage (g f x 100) Are there any other dental plans in place for your group in addition to the products offered through Univera Healthcare? Yes No If so, what carrier is your company s dental coverage with? Number of individuals in this plan *This portion only to be completed if your company has multiple locations and/or multiple plans. Only include those eligible for health insurance with other insurance carriers that are not eligible to enroll in the Univera Healthcare plan. ** The minimum number hours for groups with 50 and under eligible employees is 20 hours, and 17.5 hours for groups with 51 or more eligible employees. 5
Supplemental Form: Dental Failure to respond may result in your policy being cancelled. Class Names A001 - All Active Employees A002 - Hourly A003 - Salaried A004 - Management A005 - Non-Management A006 - Union A007 - Non-Union A008 - Full Time A009 - Part-Time Z001 - Custom Class/Other R001 - Retired Non-Medicare Eligible R002 - Retired Medicare Eligible Employer Contribution Range - % (check applicable box for single tier and family tier) Single Family Class Name Product 0% 1-24% 25-49% 50-74% 75-89% 90-100% 0% 1-24% 25-49% 50-74% 75-89% 90-100% Class Name Product 0% 1-24% 25-49% 50-74% 75-89% 90-100% 0% 1-24% 25-49% 50-74% 75-89% 90-100% Signature: The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete, including the number of persons proposed for coverage who work at least the minimum required hours per week. Employer Authorized Representative Signature Date Phone Number Print Name Email Address 6
Eligibility Policy for New Employees Group Name: Group Number {If Assigned}: Our Standard new hire waiting period for eligibility for health insurance is: Date of Hire First of the month following date of hire First of month following 30 days of employment First of month following 60 days of employment 90 days after date of hire (Type of employee: salaried, hourly, etc.) Other Must be approved by underwriting prior to submission --------------------------------------------------------------------------------------------------------------------------------- Our Standard rehire waiting period for eligibility for health insurance is: Same guidelines as new hire Date of rehire First of the month following rehire Other Must be approved by underwriting prior to submission Minimum hours per week that an employee must work to be eligible: Note: 20 hours 25 hours 30 hours 40 hours. Employer can determine full time status as stated above but may not be less than 20 hours. Waiting period cannot exceed 90 days The above policies have been submitted for business indicated above. I understand that these policies are accepted and must remain in effect for at least one full year before they are eligible to be changed. Authorized Group Signature: Date Signed: Date Effective: Revised 07-08-2013
ATTESTATION I,, the (Name) at (Name of Employer) (Title) do hereby attest that: For groups with 2 or more employees, including businesses with only one employee who is eligible for health insurance coverage. Please list the individuals eligible for coverage who are not listed on the NYS-45-ATT. Eligible individuals include partners or owners of the business if actively engaged in the business, COBRA/NYS continuants, new employees, and retirees when it is the consistent policy of the business to cover retirees. The individual(s) listed below work at least 20 hours per week at the above-named Employer or are otherwise eligible for coverage under a group health insurance plan to be issued by us. Include a notation for each person indicating New Employee (E) with date of hire, Partner (P), Business Owner (B), Retiree (R), COBRA (C), or other (O) with explanation. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. I certify that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete, including that the persons proposed for coverage work at least 20 hours per week or are otherwise eligible for coverage. I understand that 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 $5000 and the stated value of the claim for each such violation. (Signature) (Date) _ Creation date: 06/23/2009 Revised date: 07/08/2013
Waiver of Group Coverage Company Name: Employee Name: Date of Birth: Health Plan (Product) Effective Date: Average number of hours working weekly I understand that I am eligible to participate in my employer s group health insurance coverage and that my employer is contributing the following amount to the health plan(s) premium: Product Name: Monthly Contribution Dollar Amount: Single $ Family $ Other (amount & tier) $ $ Product Name: Monthly Contribution Dollar Amount: Single $ Family $ Other (amount & tier) $ $ Please Check All That Apply: [ ] I waive my employer s group health insurance coverage for myself and my dependents (if any). [ ] I waive my employer s group dental insurance coverage for myself and my dependents (if any). Reason for Waiving Coverage - Please Check One: [ ] Covered through spouse s employer [ ] Covered through a parent s employer [ ] Under 65 Retiree covered by previous employer s insurance program [ ] Other Please specify: Please Read and Sign Below: In waiving coverage, I understand that I and/or my dependents may enroll under this plan in the future only as the result of certain qualifying conditions. For example, -Within 30 days of involuntarily loss of other group coverage - At the time of my employer s open enrollment. Signature: The undersigned certifies that, to the best of my knowledge and belief and under penalty of perjury, the information listed above is true and complete. Employee Signature: Date: 205 Park Club Lane Buffalo, NY 14221 5239 univerahealthcare.com Creation Date: 10/30/2009 Revision Date: 01/21/2014