Employer Application For Small Business - Illinois Page 4
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4Group Name_________________________________________________________________________________________________________
Important Information
I understand that the Certificate of Coverage or Summary Plan Description, and other documents, notices and communications regarding the
coverage indicated on this application may be transmitted electronically to me and to the Group’s employees.
I represent that, to the best of my knowledge, the information I have provided in this application – including information regarding qualified
beneficiaries and dependents who have elected continuation under COBRA or state continuation laws – is accurate and truthful. I understand
that UnitedHealthcare and Affiliates will rely on the information I provide in determining eligibility for coverage, setting premium rates, and
other purposes, and that any intentional misrepresentation, fraudulent statement, or omission that constitutes fraud may result in rescission of
the group policy, termination of coverage, increase in premiums retroactive to the policy date, or other consequences as permitted by law.
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully
presents false information, or conceals information for the purpose of misleading, in an application for insurance is guilty of a crime and may
be subject to fines and confinement in prison.
In some instances, we pay brokers and agents (referred to collectively as "producers") compensation for their services in connection with the
sale of our products, in compliance with applicable law. In certain states, we may pay "base commissions" based on factors such as product
type, amount of premium, group/company size and number of employees. These commissions, if applicable, are reflected in the premium rate.
In addition, we may pay bonuses pursuant to programs established to encourage the introduction of new products and provide incentives to
achieve production targets, persistency levels, growth goals or other objectives. Bonus expenses are not directly reflected in the premium rate
but are included as part of the general administrative expenses. Please note we also make payments from time to time to producers for
services other than those relating to the sale of policies (for example, compensation for services as a general agent or as a consultant).
Producer compensation may be subject to disclosure on Schedule A of the ERISA Form 5500 for customers governed by ERISA. We provide
Schedule A reports to our customers as required by applicable federal law. For specific information about the compensation payable with
respect to your particular policy, please contact your producer.
Signature
Group Authorized Signature
Title
Date
Producer Information (if applicable)
Writing Producer Name
Writing Producer SSN
Is the Producer appointed
with UHC?
Yes
No
All Payments to:
CRID Code (for internal use) Tax ID#
If more than 1 Producer*,
Split ______%
Street Address
City
State
Zip Code
Producer Phone #
Producer Email Address
Producer Fax Number
The contents of this application were fully explained during a meeting with the
Producer Signature
Date
Group submitting this application. Coverage, eligibility, pre-existing condition
limitations, the effect of intentional misrepresentations, and termination provisions
were discussed.
*If more than one Producer, provide the second Producer's information on an additional sheet of paper.
UHC Sales Representative/Account Executive
Sales Representative or Account Executive (First & Last Name)
General Agent Information (if applicable)
General Agent
Phone #
Franchise Code
Street Address
City
State
Zip Code
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