Employer Application For Small Business - Illinois Page 3
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4Group Name_________________________________________________________________________________________________________
Questions Regarding Group Size
Under federal law, if your group had 20 or more employees on your payroll on at least 50% of the group's working
COBRA
days during a calendar year, you must provide employees with COBRA continuation effective January 1 of the next
State Continuation
calendar year. If your group had fewer than 20 employees during a calendar year, you must provide State Continuation
effective January 1 of the next calendar year.
Medicare Primary Under federal law, if your group had 20 or more employees during 20 or more calendar weeks in the preceding calendar year,
the Health Plan is primary and Medicare is secondary. This statement does not set forth all rules governing group level Medicare
Plan Primary
status. The Group should contact its legal and/or tax advisor(s) for information regarding other rules that may impact the
Group’s Medicare status. Under federal law it is the Group’s responsibility to accurately determine its Medicare status.
Under Health Care Reform law, the number of employees means the average number of employees employed by the
Enter the Prior
company during the preceding calendar year. An employee is typically any person for which the company issues a W-2,
Calendar Year
regardless of full-time, part-time or seasonal status or whether or not they have medical coverage.
Average Total
Number of
To calculate the annual average, add all the monthly employee totals together, then divide by the number of months you were
Employees
in business last year (usually 12 months). When calculating the average, consider all months of the previous calendar year
regardless of whether you had coverage with us, had coverage with a previous carrier or were in business but did not offer
coverage. Use the number of employees at the end of the month as the "monthly value" to calculate the year average. If you
are a newly formed business, calculate your prior year average using only those months that you were in business. Use
whole numbers only (no decimals, fractions or ranges).
For purposes of determining your number of full-time equivalent employee count, the number of employees means the average
Enter the Prior
number of employees employed full-time (at least 30 hours/week in any given month), by the company on business days during
Calendar Year Full
the preceding calendar year.
Time Equivalent
Total Number of
In addition to the number of full-time employees noted above, for any month otherwise determined, include for such month the
Employees
number of full-time employees divided by the aggregate number of hours of service of all employees who are not full-time
employees for the month by 120. Employers should exclude employees who were seasonal workers who worked 120 days or
fewer in the preceding calendar year.
Yes
Do you currently utilize the services of a Professional Employer Organization (PEO) or Employee Leasing Company (ELC),
No
Staff Leasing Company, HR Outsourcing Organization (HRO), or Administrative Services Organization (ASO)?
Is your group a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), or other such entity
Yes
that is a co-employer with your client(s) or client-site employee(s)?
No
If you answered Yes, then by signing this application you agree with the certification in this section.
I hereby certify that my company is a PEO, ELC or other such entity and that only those employees that are the corporate
employees of my company, and not my co-employees, are permitted to enroll in this group policy. If my group at any
point after I sign this application determines that the group will provide coverage to the co-employees under the group's
plan, I understand that UnitedHealthcare will not cover the co-employees under this group policy.
Does your group sponsor a plan that covers employees of more than one employer?
Yes
No
If you answered Yes, then indicate which of the following most closely describes your plan:
Professional Employer Organization (PEO)
Governmental
Multiple Employer Welfare Arrangement (MEWA)
Church
Taft Hartley Union
Employer Association
Yes
Do you have common ownership with any other businesses? If you own multiple companies, or a parent-subsidiary
No
relationship exists between your company and another, this may indicate common ownership of businesses.
Current Carrier Information
Does the group currently have any coverage with UnitedHealthcare or has the group had any UnitedHealthcare coverage in the last 12 months?
Yes
No If Yes, please provide policy number ______________________ and Coverage Begin Date___/___ /___ End Date___/___ /___
Has this group been covered for major dental services for the previous 12 consecutive months?
Yes
No
Initial Coverage
Name of Carrier
Begin Date
Coverage End Date
Current Medical Carrier
None
Current Dental Carrier
None
Current Life Carrier
None
Current Disability Carrier
None
Current Vision Carrier
None
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