Form 60036 - Health Insurance Application Or Change (Page 3 of 3) in pdf

HEALTH INSURANCE APPLICATION OR CHANGE

SFN 60036 (Rev.03-2016) Page 3 of 3

Workers’ Compensation/No-Fault

Are you, your spouse or any of your Eligible Dependents currently receiving or have received worker’s compensation benefits?

Yes

Are you, your spouse or any of your Eligible Dependents currently receiving no-fault benefits?

Yes

Person’s Name

Injury Date

Type of Injury

Company Providing Benefits & Phone Number

(MM-DD-YY)

PART F

EMPLOYER CERTIFICATION OF ACA ELIGIBLE TEMPORARY EMPLOYEE

I certify that this employee meets the definition of a full-time employee under the Affordable Care Act and as such,

is being offered coverage. Check appropriate method of determination:

Monthly Measurement

Date of New Hire: ____/____/____

Date of Change in Position/Increase in Hours: ____/____/____

Look-back Measurement

The current measurement period used by the employer is: From:_____/_____

To:_____/_____

This information is required for NDPERS to determine enrollment eligibility.

_________________________________________

________________________________

Authorized Agent’s Signature

Date of Signature

PART G

MEMBER AUTHORIZATION

I understand that any company(s) with which I am applying for coverage reserves the right to accept or decline

this application in whole or in part. I further understand that no contractual right is created by this application or

advance premium payment and the same shall not be considered accepted unless or until the Benefit Plan is

issued to me. I have read this application in its entirety (front and back page) and understand and acknowledge

that the accuracy and sufficiency of the information I provide (or fail to provide) in each and every numbered

section of this application serves as the basis in determining my eligibility (and the eligibility of my dependents) for

coverage and receiving a Benefit Plan(s), and by signing this application I certify the information is accurate and

complete. I understand and agree that inaccurate, incomplete or omitted information represented in this

application may constitute a fraudulent act or intentional misrepresentation of material facts voiding or retroactively

cancelling any Benefit Plan(s) issued, as well as any claims for medical benefits and services paid, based on the

information I submit through this application. I further understand a person who submits an application or files a

claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

I understand members are subject to limitations and exclusions outlined in the relevant Benefit Plan/Policy.



I understand that in the event the group through which I am enrolled elects to terminate, the Insurance



Carrier has the right at its sole discretion to continue my coverage on a non-group basis subject to the

premium and Benefit Plan provisions for non-group coverage then in effect.

I understand conversion coverage will not be offered to a Subscriber if the group through which the



Subscriber is eligible has terminated coverage with the Insurance Carrier and has enrolled as a group with

another Insurance Carrier.

I understand, in the event my employer adopts the method of payroll deduction, I hereby authorize and



direct my employer to deduct the current premium from my wages or salary and remit to NDPERS.

I acknowledge that the Summary of Benefits and Coverage and other related plan information is available



on the NDPERS website at

Please retain a copy of this Application for your records

_________________________________________

_________________________________

Member’s Signature

Date of Signature

Form 60036 - Health Insurance Application Or Change Page 3

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