Form Oci 26-501 - Uniform Employee Application (Page 3 of 9) in pdf

_______________________

Employee Name

6. RESPIRATORY SYSTEM

9. CANCER

a) allegry(ies)

[ ] Yes [ ] No

a) cancer

[ ] Yes [ ] No

b) asthma

[ ] Yes [ ] No

b) tumor

[ ] Yes [ ] No

c) emphysema

[ ] Yes [ ] No

c) abnormal growth

[ ] Yes [ ] No

d) sinus or nasal disorder

[ ] Yes [ ] No

d) carcinoma in situ

[ ] Yes [ ] No

e) lung disease or disorder

[ ] Yes [ ] No

f) shortness of breath

[ ] Yes [ ] No

10. BEHAVIORAL HEALTH

7. NERVOUS SYSTEM

a) attention deficit disorder

[ ] Yes [ ] No

a) epilepsy or other seizures

[ ] Yes [ ] No

b) psychological disorder

[ ] Yes [ ] No

b) headaches

[ ] Yes [ ] No

c) suicide attempt

[ ] Yes [ ] No

c) multiple sclerosis

[ ] Yes [ ] No

d) eating disorder

[ ] Yes [ ] No

8. MUSCULAR or SKELETAL

a) arthritis

[ ] Yes [ ] No

11. OTHER

b) fibromyalgia

[ ] Yes [ ] No

a) organ or other type of transplant or implant

[ ] Yes [ ] No

c) back disorder

[ ] Yes [ ] No

b) breast disorder

[ ] Yes [ ] No

d) joint disorder

[ ] Yes [ ] No

c) lupus

[ ] Yes [ ] No

e) musculoskeletal disorder

[ ] Yes [ ] No

f) skin disorder

[ ] Yes [ ] No

g) chronic fatigue syndrome

[ ] Yes [ ] No

G. Within the last 5 years, has anyone named in this application to be covered by this insurance had any other injury, illness or treatment for any

condition not already listed; been hospitalized or been scheduled for hospitalization; had surgery or had surgery scheduled; had a test or a test

scheduled; or been recommended to have a test or surgery which was not performed for any reason not already mentioned in this application?

We are not seeking the results of HIV Antibody test.

[ ] Yes [ ] No

H. In the space below please list and provide the complete details if you answered “Yes” above to any of the questions or conditions contained in

sections A through G. (Attach additional pages as needed and sign the additional pages.)

Give full details for each question answered

Name and address of attending

Question

Date(s) of

“Yes,” state the condition, duration and degree

physician or other health care

Number

Name of Person

Treatment

of recovery.

provider.

If anyone named in this application is taking medication or has had prescribed or recommended any medication during the period of time related

to your answer (i.e. past 5 years, past 10 years, or currently taking), please list all those medications, dosages, and what medical condition is

being treated or were treated by each medication in the space provided below. (Attach additional pages as needed and sign the additional

pages.)

Name, dosage and frequency of medication

Name and address of prescribing

(include illness or health condition for which

Date(s) medication taken

physician or licensed health care

Name of Person

medication was prescribed)

(indicate if ongoing)

provider and dispensing pharmacy

V. WAIVER OF COVERAGE

I understand that I am eligible to apply for group health insurance through my employer. I do NOT want, and hereby waive, group health insurance

for (check the box that applies):

[ ] Waiving for myself

[ ] Waiving for my spouse

[ ] Waiving for my dependent child(ren)

[ ] Waiving for me, my spouse and my dependent child(ren)

I am waiving group health insurance because (check all that apply):

[ ] I, the employee, am covered or will be covered under another plan that is not sponsored by my employer. I am not enrolled for coverage under

the Health Insurance Risk-Sharing Plan (HIRSP). If currently covered, please attach a copy of your identification card for that plan.

[ ] I, the employee, do not have a risk characteristic or other attribute that would be the sole cause for the small employer insurer to make a

decision with respect to premiums or eligibility for a policy that is adverse to the small employer.

Uniform Employee Application

Page 3 of 9

OCI 26-501 (R 6/2010)

Form Oci 26-501 - Uniform Employee Application Page 3

Related Articles

Related forms

Related Categories