Form Acc-Port - Request For Portability Of Accident Insurance Page 2

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Request for Portability of Accident Insurance*
F. Quarterly or Annual Premium Calculation
Please choose either Quarterly or Annual billing:
Quarterly or
Annual
Quarterly Premium Calculations
Annual Premium Calculations
Employee’s quarterly premium is calculated:
Employee’s annual premium is calculated:
(a.) Monthly premium x 1.10 = $
(a.) Monthly premium x 1.10 $
________
________
(b.) Multiply (a.) x 3 =$
.**
(b.) Multiply (a.) x 12 = $
_______
______.**
**This is your new Quarterly Premium
**This is your new Annual Premium
If you are requesting portability coverage for your spouse and/or dependents, a sim ilar calculation should be done for
your Spouse and Dependent Child(ren) and listed below .
Employee’s premium amount:
$__________
Spouse’s premium amount:
$__________
Dependent’s premium amount: $__________
Total payment required with this form (Employee + Spouse+ Dependents): $_____________
G. Employee Signature
Enclosed with this form is my first quarter or annual premium. I hereby authorize UnitedHealthcare Insurance
Company to begin billing me directly for my Accident Insurance coverage.
Insured Employee
Date
________________________________________________________
__________________________
Make your check payable to UnitedHealthcare Specialty Benefits
Mail this completed form with your premium to:
UnitedHealthcare Specialty Benefits
th
9700 Health Care Lane – 8
Floor
MN017-E800
Minnetonka, MN 55343
1-877-683-8601
UnitedHealthcare Specialty Benefits’ insurance products are underwritten by UnitedHealthcare Insurance Company
(rated A+ by Standard & Poors). Some products may not be available in certain states.
UnitedHealthcare Specialty Benefits Use Only
Date Received
Date Acknowledgement Mailed
Group Number
ACC-Port (12/12)
*In some states, Portability may be referred to as Continuation

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