Form 60036 - Health Insurance Application Or Change Page 2
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3HEALTH INSURANCE APPLICATION OR CHANGE
SFN 60036 (Rev.03-2016) Page 2 of 3
Section 3
Level Of Coverage for Plan:
Single Coverage (Self Only)
Family Coverage (Self and Spouse OR Self and Eligible Child(ren) OR Self, Spouse, Eligible Child(ren)
PART C
DEPENDENT INFORMATION
List all family members to be covered under the plan indicated in Part B, Section 1, other than yourself.
1.
Indicate dependent’s address below name if address is different from yours.
a.
For Relationship to you, enter one of the following: Spouse, child, stepchild, adopted child, legal
b.
guardian, or grandchild.
For Marital Status, enter one of the following: (S) Single, (M) Married, (D) Divorced, or (W) Widowed
c.
If your marital status is single and you are applying for family coverage, you are required to attach a copy of
2.
the state birth certificate for each Eligible Dependent unless previously submitted.
If you are adding a grandchild, a Grandchild Eligibility Verification SFN 60983 must be submitted also, along
3.
with a copy of the child’s birth certificate.
In compliance with the Federal Privacy Act of 1974, the disclosure of the individual's social security number on
this form is mandatory pursuant to 26 U.S.C. Section 3402. The individual's social security number will be used
for tax reporting and as an identification number.
Dependent Name (last, first, middle)
Relationship
Gender
Date
Social Security
Marital
Court
Active
If address is different then subscriber,
of Birth
Number
Status
Ordered
Military
indicate address under name
Coverage
No
Spouse
N/A
Yes
No
No
Yes
Yes
No
No
Yes
Yes
PART D
MEDICARE COVERAGE INFORMATION
Are you or spouse or any of your Eligible Dependents currently covered by Medicare?
No, skip to next section
Yes, complete the following:
Are you or spouse or any of your Eligible Dependents currently covered by Medicare due to End Stage Renal Disease?
No, skip to next section
Yes, complete the following:
Medicare Part A Effective
Medicare Part B Effective
Individual on Medicare (Last, First, Middle)
Medicare Claim Number
Date
Date
PART E
OTHER COVERAGE INFORMATION
Are you, your spouse or any of your Eligible Dependents currently or were previously covered by another insurance benefit
plan(s), INCLUDING NDPERS BENEFIT PLAN(S)?
No, skip to next section
Yes, please complete this section AND
attach Certificate(s) of Coverage or other documentation from your insurance company. Failure to provide
documentation may affect your waiting period.
Other Coverage Name
Policyholder
Date of
Policy Coverage
Policy Number
& Phone Number
(last, first, middle)
Birth
Dates (mm-dd-yy)
Name(s) of Person(s) Covered
From:
To:
From:
To:
Do you intend to keep your current policy (ies) in force after the effective date of this Application?
Yes
No, Why? _______________________________________________________________________________________________
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