Form Uh00674 - Employee Application Page 2
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1
2OTHER INSURANCE INFORMATION:
Will you or any of your dependents continue to have other insurance, including Medicare, after the Unity Health Insurance effective date of this policy?
If Yes, complete –
Name(s) of Insured
Employer
Insurance Company
Subscriber #
Group #
Effective Date of Coverage
Insurance Company Phone #
Do you or any dependents have medical coverage that has ended or will end within 30 days? If Yes, complete –
Insurance Company
Phone #
Subscriber #
Effective Date of Coverage
Termination Date
Names of those covered under policy
Are you or any dependents listed above involved in a Workers Compensation case?
Yes
No
If Yes, indicate who is involved and start date / accident date:
Workers Compensation Condition:
Insurance Company Name
Insurance Company Address (where claim is sent)
Insurance Company Phone Group #
Effective Date: Term Date (if applicable):
WAIVER of GROUP COVERAGE:
I elect not to apply for the Group Health Benefit Plan coverage:
Employee
Spouse
Children
Reason for waiving coverage:
(please see back of form for additional information)
I / we will be covered by a health benefit plan which provides similar benefits. Name of Insurance Company:
I / we will be enrolled in a similar health benefit plan offered by my employer. Name of Insurance Company:
The annualized premium contribution to be paid by me for Unity would exceed 10% of my annualized gross earnings.
Other
I understand that group enrollment and / or eligibility for benefits may be conditioned upon my willingness to provide Unity with additional health information
from me, my spouse or any dependents applying for coverage under this application. To the best of my knowledge, all statements and answers in this application
are complete and true. I understand that any fraudulent statement or intentional misrepresentation of material fact may result in denial of a claim and / or
rescission of coverage.
Date: _____________________________ Employee Signature: ____________________________________________________________________________
NOTICE OF SPECIAL ENROLLMENT RIGHTS
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you
may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops
contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your dependents’ other
coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth,
adoption or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the
marriage, birth, adoption or placement for adoption.
UH00674 (rev 01 16)
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Parent category: Business