Employer Application For Small Business - Illinois
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Employer Application for Small Business
Illinois
UnitedHealthcare Insurance Company
I I
UnitedHealthcare Insurance Company of Illinois
I I
To avoid processing delays, please make sure you:
UnitedHealthcare of Illinois, Inc.
1 Answer all questions completely and accurately.
I I
UnitedHealthcare Insurance Company of the River Valley
2 Complete and submit the Product and Benefit Selection Form, if applicable.
I I
3 Submit the most recent billing statement listing those currently insured and
UnitedHealthcare Plan of the River Valley, Inc.
I I
current status.
4 Submit most recent wage and tax information.
5 Include a deposit check for any required premiums.
6 DO NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN
NOTIFICATION OF APPROVAL.
Requested Effective Date
General Information
Group’s Legal Name
Group Name to appear on ID card (maximum 30 characters)
Street Address
Tax ID
City
State
Zip Code
Names of Owners/Partners (if applicable)
Internet access?
Yes
No
Contact Person
Email Address
# of Years
in Business
Billing Address (If Different)
Telephone
Fax
Multi-Location Group* # Locations
Address(es) (or list on additional sheet of paper)
Yes
No
*If the majority of your employees are not located in your state of application, UnitedHealthcare policies and/or state law may require that your
policy be written out of a different state and/or that your benefit plans vary.
Organization Type
Partnership
C-Corp
S-Corp
LLC
LLP
Medical Benefit
Domestic Partner Coverage
Sole Proprietor
Other_________________________________________
Plan Option
Yes
No
Did you have any employees other than yourself and your spouse during the
Calendar Year
preceding calendar year?
Yes
No
Policy Year
Waiting Period for new hires
1st of Policy Month following Date of Hire
Waiting Period
1st of Policy Month following ____
months
days of employment
for initial enrollees
(Waiting period for medical
Date of Hire (no waiting period)
Yes
No
coverage cannot exceed 90 days)
____
months
days of employment following Date of Hire
Classes Excluded:
None
Union
Hourly
Nature of Business
Industry (SIC) Code
Non-Management
Salary
Have Workers’ Comp
Workers’ Comp Carrier Name
Names of Owners/Partners not covered by Workers’ Comp:
Yes
No
Names of Persons currently on COBRA/Continuation, and/or Short/Long Term Disability:
See Attached List
None
By checking this box, I acknowledge that I do NOT want UnitedHealthcare to act as my COBRA or state continuation of coverage administrator.
Coverage Provided by “UnitedHealthcare and Affiliates”:
Medical coverage provided by UnitedHealthcare Insurance Company, UnitedHealthcare Insurance Company of Illinois, UnitedHealthcare of Illinois, Inc.,
UnitedHealthcare Insurance Company of the River Valley, or UnitedHealthcare Plan of the River Valley, Inc
Dental coverage provided by UnitedHealthcare Insurance Company or Dental Benefit Providers of Illinois, Inc.
Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company
Vision coverage provided by UnitedHealthcare Insurance Company
Page 1 of 4
SG.ER.16.IL 4/15
230-11119 2/16
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