Form Uh00674 - Employee Application
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1
2840 Carolina Street
EMPLOYEE APPLICATION
Sauk City, WI 53583-1374
(800) 362-3309
Fax (608) 643-2564
Please Complete Entire Form in BLACK INK.
EMPLOYMENT INFORMATION:
Name of Employer Group:
Hours Worked Per Week:
_____/_____/_____
_____/_____/_____
Employment Status:
Active
Retired
LOA
Requested Effective Date of Coverage:
Date Employed:
Plan Requested:
HMO ______________________________
POS ______________________________
PPO ______________________________
Type of Coverage:
Employee
Employee and Spouse
Employee and Child(ren)
Family
Reason for
_____/_____/_____
New Hire
Marriage Date
Loss of Other Insurance
Add a Dependent
Name Change
Open Enrollment
Enrollment:
EMPLOYEE INFORMATION (Please do not use abbreviations or nicknames on this application)
Applicant’s Last Name
First Name
MI
Social Security Number or Tax ID Number
____ ____ ____ – ____ ____ – ____ ____ ____ ____
Mailing Address
City
State
Zip Code
County
Date of Birth
Gender
Marital Status
Primary Language Spoken
Single
Divorced
_____/_____/______
M
F
Married____________________________________
English
Spanish
Other_________________
Home Phone # (
)
Work Phone # (
)
Cell Phone # (
)
Applicant’s E-Mail Address:
*Primary Care Physician (PCP) and Clinic:
Current Patient?
Yes
No
*If you want Unity to assign you to a Clinic or a PCP, indicate “ASSIGN”
APPLICANT INFORMATION – Please list all other Members to be covered:
Dependent Name (Last, First, MI)
Social Security Number or Tax ID Number
___ ____ ____ – ____ ____ – ____ ____ ____ ____
Mailing address if different than subscriber:
Relationship
Date of Birth
Gender
*Clinic and PCP Name
Current patient?
Yes
No
_____/_____/______
M
F
Dependent Name (Last, First, MI)
Social Security Number or Tax ID Number
___ ____ ____ – ____ ____ – ____ ____ ____ ____
Mailing address if different than subscriber:
Relationship
Date of Birth
Gender
*Clinic and PCP Name
Current patient?
Yes
No
_____/_____/______
M
F
Dependent Name (Last, First, MI)
Social Security Number or Tax ID Number
___ ____ ____ – ____ ____ – ____ ____ ____ ____
Mailing address if different than subscriber:
Relationship
Date of Birth
Gender
*Clinic and PCP Name
Current patient?
Yes
No
_____/_____/______
M
F
Dependent Name (Last, First, MI)
Social Security Number or Tax ID Number
___ ____ ____ – ____ ____ – ____ ____ ____ ____
Mailing address if different than subscriber:
Relationship
Date of Birth
Gender
*Clinic and PCP Name
Current patient?
Yes
No
M
F
_____/_____/______
UH00674 (rev 01 16)
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Parent category: Business