Idaho Small Group Application Page 3
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4WAIVER OF COVERAGE
SECTION 5
(To be completed only if coverage is declined or refused by an eligible employee or dependents.)
1. I decline coverage for:
Self (name) ____________________________________
Dependent (name) _______________________________
Spouse (name) _________________________________
Dependent (name) _______________________________
Dependent (name) ______________________________
Dependent (name) _______________________________
2. Reason for declining coverage (check all that apply):
I and/or my dependents currently have other qualifying medical coverage with (name of carrier) ________________
________________________________________________________through:
My other employer
My spouse’s employer
Individual policy
Medicare
Medicaid
Tricare
Indian Health Services
OR
Other reason for declining coverage (please explain): _________________________________________________
SIGNATURE TO WAIVE**
I have decided to waive coverage as indicated above. I have been given the opportunity to apply for group coverage by the
employer. Should I decide to apply for this coverage in the future, I realize and agree any coverage may be subject to
additional probationary waiting periods.
(mm/dd/yyyy)
**Signature ____________________________________________________ Date _____________________________
(sign only if waiving coverage)
mm/dd/yyyy
Notice of enrollment rights: If you are declining enrollment for you or your dependents (including your spouse) because of other health
insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request
enrollment within 30 days after your other coverage ends. 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, provided that you request enrollment
within 60 days after the marriage, birth, adoption or placement for adoption.
SECTION 6
OTHER COVERAGE INFORMATION
(Please complete the section below if you have other coverage that will
remain in effect. If you have more policies to include, make a copy of this page and attach.)
If coverage is provided for a dependent from a previous marriage or relationship, please attach a copy of the court documentation that shows who is
responsible for the dependent(s)’ health care insurance so that the insurance carrier can determine whose coverage is primary.
Other Policy
1. Other Insurance Carrier Information: Insurance Carrier Name, Policy Number, Phone Number
2. Policy Holder Name
3. Names of Covered Members
7. Coverage End Date
5. Coverage Start Date
4. Types of Coverage
6. Is this coverage terminating?
mm/dd/yyyy
(check all that apply)
mm/dd/yyyy
Yes (complete #7)
Group
Dental
Individual
Vision
No
Medicare
(mm/dd/yyyy)
(mm/dd/yyyy)
OTHER INFORMATION
SECTION 7
Are you or any of your dependents listed on this application currently disabled? No Yes
1.
Name of disabled person ________________________________
Physician’s name and phone _______________________________
Date of disability _______________________________________
Physician’s address ______________________________________
(mm/dd/yyyy)
Nature of disability_______________________________________________________________________________________________
2.
Are you or any dependent listed on this application covered on Medicare or have received Social Security Disability or Worker’s
Compensation payments or are now eligible to receive such payments? No Yes
If yes, give person’s name, specific type and details: __________________________________________________
_____________________________________________________________________________________________
3.
Has any person listed on this application used a tobacco product on average four or more times a week within no longer than the past six
months (anyone age 18 or older)?
No
Yes If yes, list names below:
1.
_________________________________________
3.
___________________________________________________
2.
_________________________________________
4.
___________________________________________________
FOR OFFICE USE ONLY
Electronic System ID
Form No. ISE-APP-1-2014
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