Form Oci 26-501 - Uniform Employee Application Page 5
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9_______________________
Employee Name
Effective
Termination
Type of
Date of
Date of
Coverage
Insurance Company, Plan &
Coverage
Coverage
Reason for Termination of
(see key
Name
Group Number
(mo/day/yr)
(mo/day/yr)
Coverage
below)
Type of Coverage Key: G = Group Comprehensive Major Medical; I = Individual Comprehensive Major Medical;
M = Medicare Supplement; D = Drug Coverage Only; H = Hospital Coverage Only; V = Vision Coverage Only
VIII. HEALTH PROVIDER OR PRODUCT SELECTION, IF APPLICABLE
This section should be completed only if the small employer group insurance for which you are applying requires the selection of a network, primary
care provider or clinic. If applicable, it should also be used to select the product options offered by the employer or insurer. With respect to the
provider or network selection, a selection should be made for each individual applying for such coverage and for each insurer from which insurance
coverage is being sought. The provider numbers may be listed in the provider materials (i.e., directory) that are supplied by each insurer to your
employer. The provider numbers for the same provider may not be the same for different insurers or products. Use additional sheets if
necessary.
Insurer: ____________________________________________________________
Product Type: _______________________________________________________
Coinsurance Option: _______________
Deductible Option: _______________
Copayment Option: _______________
Selected Provider is for (choose only one): [ ] Health Insurance [ ] Dental Insurance [ ] Other ______________________________
Is this your current
Covered Person’s Name
Network or Provider’s Name or Number
provider?
Insurer: ____________________________________________________________
Product Type: _______________________________________________________
Coinsurance Option: _______________
Deductible Option: _______________
Copayment Option: _______________
Selected Provider is for (choose only one): [ ] Health Insurance [ ] Dental Insurance [ ] Other ______________________________
Is this your current
Covered Person’s Name
Network or Provider’s Name or Number
provider?
IX. NON-HEALTH INSURANCE COVERAGE SELECTION, IF APPLICABLE
Availability of coverage is determined by your employer and whether the coverage is approved for issuance by the insurer(s).
Please list the insurer(s) below from whom you are applying for coverage and check all benefits for which you are applying.
If you have been given a choice of plans to apply for, or if the coverage you are applying for requires the selection of a primary care
provider/clinic/network, please complete the section entitled "Provider and/or Product Selection."
If you are waiving application for any coverage on yourself and/or your spouse and/or dependent child(ren), please complete the "Waiver of
Coverage" section at the end of this section.
Uniform Employee Application
Page 5 of 9
OCI 26-501 (R 6/2010)
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