Account Evaluation Form - United Healthcare
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1Account Evaluation Form
Please fill out the information below to the best of your knowledge. Do not seek any additional information directly from your employees.
Company Name:____________________________________________________________
Employer Questions
- If the answer is “Yes” for any of the following, please give explanation below.
A. Have any employees or any other family members incurred medical and or hospital expenses of $10,000 or more in
❑ Yes ❑ No
the past two years?
B. Are any employees or dependents currently covered due to 1)COBRA/state continuance, 2)Extension of Benefits,
❑ Yes
❑ No
or 3)Short or Long Term Disability [STD-LTD]?
C. How many employees or dependents are pregnant? __________________________
D. In the past two years, have any employees or any other family member(s) been confined to a hospital for a mental/
nervous disorder, alcohol or drug abuse, a congenital disorder or for a defect existing from birth? ❑ Yes ❑ No
E. In the past two years, have any employees or any other family member(s) had treatment, attention, or advice from a
physician for cancer, heart disease or disorder, stroke, kidney/bladder disease, diabetes, liver disorder, high blood
presure, brain disorder, Acquired Immune Deficiency Syndrome (AIDS), AIDS related conditions, alcohol or drug
❑ Yes
❑ No
abuse or any other serious medical order?
F.
Have any employees and/or dependents been advised to undergo medical treatment, surgical operations, diagnostic
testing or hospitalization in the next six months? ❑ Yes ❑ No
Additional Information for Questions A-F
Diagnosis
Age
Dollar amount of claim
Current
Date
Related Information
and/or length of stay
Condition
COBRA and/or STD-LTD Information
Reason for Continuance
Age
Health Condition
Date Continuance or
or disability
Disability Will End
Broker/Agent Signature:__________________________________________________________
Date:_____________
Customer Signature:______________________________________________________________
Date:_____________
MS-02-1389 AccEvalForm
5869 R3
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Parent category: Medical