Form Oci 26-501 - Uniform Employee Application printable pdf download

_______________________

Employee Name

SMALL EMPLOYER UNIFORM EMPLOYEE

State of Wisconsin

APPLICATION FOR GROUP HEALTH

Office of the Commissioner of Insurance

INSURANCE

P.O. Box 7873

Madison, WI 53707-7873

Ref: Section Ins 8.49, Wis. Adm. Code, and

(608) 266-3585

Sections 601.41 (8), 635.10, Wis. Stat.

Web Address: oci.wi.gov

This form is designed for an employer’s initial application for coverage. Please contact your agent or the insurer to determine if this form

should be used in other situations once the group is enrolled with the insurer.

EMPLOYER INFORMATION – To be filled out by Employer

Employer Name _______________________________________

Group Number _______________

Division Number ____________

Employee Class __________________

Total number of permanent employees who have a normal work week of 30 or more hours _________

Names of Insurers to whom information may be released:

Insurer: _________________________________________________

I. EMPLOYEE INFORMATION

Employee Instructions: Please print using black or blue ink. Please fill out the entire application for each person for whom coverage is

being sought.

Employee’s First Name, Middle Initial and Last Name: ________________________________________________________________________

Social Security No.: ____________________ Birth Date: ____________________ Sex: _________ Height and Weight:___________________

Street or Post Office Address: ___________________________________________________________________________________________

City: ___________________________________

County:_____________________

State: __________________

Zip: ________________

Home Phone: __________________ Work Phone: __________________ Email: _______________________________ [ ] Home [ ] Work

For your current employer: What was your first day of employment? ____/____/____

How many hours, on average, do you work each week? ______

Are You:

[ ] Single

[ ] Married

[ ] Legally Separated

[ ] Divorced

[ ] Widow or Widower

If you are married, legally separated, divorced or widowed, please indicate the date that the event occurred: _____________________

If you are married, please indicate the county and state, or country in which you were married: _____________________

If you are married, please indicate your former or maiden name: _______________________________________________

A Retiree? [ ] Yes [ ] No

On COBRA or State Continuation? [ ]Yes [ ] No

If “Yes,” provide start date and reason: ____________________________________________________________________________

II. TYPE OF HEALTH COVERAGE

Please select the type of health insurance coverage for which you are applying:

[ ] Employee Only

[ ] Employee and Spouse

[ ] Employee and Dependent Child(ren)

[ ] Employee, Spouse and Dependent Child(ren)

III. DEPENDENT INFORMATION

List all dependents, spouse and child(ren) applying for insurance. If you need additional space, please use a separate sheet of paper and

attach it to this application (please sign and date the additional sheet).

Name

Social Security

Birth Date

Height

(First; M.I.; Last)

Sex

Number

Relationship

(Mo/Day/Yr)

Weight

Spouse

[ ] Child

[ ] Stepchild

[ ] Grandchild

[ ] Other

____________

[ ] Child

[ ] Stepchild

[ ] Grandchild

[ ] Other

____________

Uniform Employee Application

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OCI 26-501 (R 6/2010)

Form Oci 26-501 - Uniform Employee Application

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