Form Oci 26-501 - Uniform Employee Application (Page 4 of 9) in pdf

_______________________

Employee Name

[ ] My spouse is covered or will be covered under another plan that is not sponsored by this employer. My spouse is not enrolled for coverage under

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

[ ] My dependent child(ren) is covered or will be covered under another plan that is not sponsored by my employer. My dependent child(ren) is

not enrolled for coverage under the Health Insurance Risk Sharing Plan (HIRSP). If currently covered, please attach your identification card for

that plan. Please list, below, the name(s) of the child(ren) for whom coverage is being waived.

[ ] I am not enrolled under the Health Insurance Risk-Sharing Plan (HIRSP) and the annualized premium contribution to be paid by me on behalf

of myself or my dependent spouse and child(ren) would exceed 10% of my annualized gross earnings from this employer.

[ ] Other reason (Please provide a written reason for waiving coverage):

________________________________________________________________________________________________________________

WAIVER: I certify that I have been given the opportunity to apply for group health insurance and decline to enroll as indicated above, on behalf of

myself, my spouse and my dependent child(ren). I understand that by signing this waiver, I, my spouse, and my dependent child(ren) forfeit the right

to coverage. I was not pressured, forced or unfairly induced by my employer, the agent or the insurer(s) into waiving or declining the group health

insurance. If in the future I apply for coverage, I, my spouse, or any of my dependent child(ren) may be treated as a late enrollee and subject to

postponement or an exclusion of coverage for preexisting conditions for a period of up to 18 months. This period may be offset by the time I, my

spouse or my dependent child(ren) was covered under a qualified health plan.

I understand that if I am declining enrollment for myself, my spouse, or my dependent child(ren) because of other health insurance coverage,

including Medicaid, I may in the future be able to enroll myself, my spouse, or my dependent child(ren) in this plan, provided that I request enrollment

within 30 days after my other health coverage ends or 60 days after Medicaid ends. In addition, if I gain a dependent spouse or child(ren) as a result

of marriage, birth, adoption, or placement for adoption, I understand that I may be able to enroll myself, my spouse and my dependent child(ren),

provided that I request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. If I am declining enrollment for

myself, my spouse or my dependent child(ren) because of coverage under Medicaid, I understand that if I, my spouse or my dependent child(ren)

become eligible for group health plan premium assistance under Medicaid, I may be able to enroll myself, my spouse or my dependent child(ren),

provided I request enrollment within 60 days of initial eligibility for the premium assistance. I understand that I can obtain enrollment information from

my employer or small employer group health insurance carrier.

Signature of Employee: _________________________________________________

Date Signed: _________________________

VI. MEDICARE INFORMATION

If you need to complete this section for more than one person, please use a separate sheet of paper and attach it to this application (please

sign and date the additional sheet).

Are you, your spouse or your child(ren) covered by Medicare Part A? [ ] Yes [ ] No Medicare Part B? [ ] Yes [ ] No Medicare Part D [ ] Yes [ ] No

Name of person covered by Medicare: ____________________________________

If “Yes,” reason for Medicare: [ ] Over Age 65 [ ] Disability [ ] End-Stage Renal Disease (ESRD) [ ] Disability and ESRD

Medicare Part A Effective Date: _________________

Medicare Part B Effective Date ___________________

Medicare Part C (Medicare Advantage) Effective Date: __________________ Medicare Part D Effective Date: ____________________

VII. CURRENT AND PREVIOUS COVERAGE

The information you provide about your other individual or group health insurance coverage (either prior or current) is necessary to determine

whether you will have any waiting periods for preexisting conditions under the group health insurance plan under which you are applying for

coverage. Your information will also help the small employer insurer(s) to coordinate benefits with any other group health coverage you may have.

By providing this information you are not reducing your group health insurance for which you are applying.

Do you, your spouse or your dependent child(ren) listed in this application have current health insurance coverage or had

previous health insurance coverage within the last 18 months? [ ] Yes [ ] No

If “Yes,” please complete the following table and attach a copy of the Certificates of Creditable Coverage for each person.

Starting with you, the employee, identify each person applying for insurance and include information for all current and previous health insurance

coverage(s) in effect during the last 18 months.

Uniform Employee Application

Page 4 of 9

OCI 26-501 (R 6/2010)

Form Oci 26-501 - Uniform Employee Application Page 4

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