Idaho Small Group Application
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4GROUP
(mm/dd/yyyy)
Group Number _____________ Effective Date _____________ Subgroup _____________ Class _____________
INFORMATION
IDAHO SMALL EMPLOYER APPLICATION
FOR ENROLLMENT OUTSIDE OF THE IDAHO EXCHANGE
Please type or print legibly in black ink and complete all applicable sections.
SECTION 1
EMPLOYER/EMPLOYMENT INFORMATION
1. Name of Employer
2. Phone Number
(xxx) xxx-xxxx
(
)
3. Address
4. City
5. State
6. Zip Code
7. Occupation
8. Hours Worked Per Week
9. Date You Started Work
(mm/dd/yyyy)
(mm/dd/yyyy)
SECTION 2
APPLICANT INFORMATION (Employee)
1. Legal First Name, Middle Name, Last Name
(and suffix, if applicable)
2. Mailing Address
(Street, Route, P.O. Box)
3. City
4. State
5. Zip Code
6. County
7. Preferred Daytime Phone Number
8. Email Address
9. Date of Birth
(mm/dd/yyyy)
(xxx) xxx-xxxx
Email address
(mm/dd/yyyy)
10. Gender
11. Social Security Number
12. Marital Status
Male
Female
(required)
Single
Married
Other ___________________________________
If you wish to waive coverage for you and/or any dependents at this time, please complete Section 5—Waiver of
Coverage. If you wish to enroll yourself and/or your dependents, please complete all sections except Section 5.
SECTION 3
ENROLLMENT INFORMATION (check all that apply)
Enrolling during your employer’s open enrollment
1. Are you:
A new applicant
Adding dependents
2. If you are enrolling outside of your employer’s open enrollment or adding dependents, what is the reason
?
Marriage
Divorce
Birth
Adoption
Involuntary loss of employer
(documentation may be required)
coverage
Involuntary loss of individual coverage
Involuntary loss of Medicaid
Court order
Other ______________________________________________________
(copy of court order required)
(mm/dd/yyyy)
Date of event
_____________________________________
(mm/dd/yyyy)
3. Type of enrollment:
Self only Self and legal spouse Self and dependent(s) Self, legal spouse and dependent(s)
4. Current employment status:
Actively at work COBRA participant Disability Other ______________________________________
(mm/dd/yyyy)
5. Requested effective date
:
______________________________________
(subject to approval)
(mm/dd/yyyy)
FOR OFFICE USE ONLY
Electronic System ID
Form No. ISE-APP-1-2014
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