Fillable Idaho Small Group Application (Page 4 of 4) in pdf

AFFIRMATION

SECTION 8

I affirm the answers in this “Idaho Small Employer Application” are complete and correct. I am providing these answers as part of the application procedure

required by this insurance carrier to enroll in its insurance coverage. I understand that the insurance carrier will rely on each answer in making its determination

to extend coverage and to determine the type of coverage offered. I understand if I have made any misstatement or omission in this application, the insurance

carrier may take any action available by law, including but not limited to, retroactive adjustment of premiums or claims. Further, I understand that any fraud or

intentional misrepresentation of material fact in my completion of this application is cause for retroactive termination of coverage by the insurance carrier and/or

other action available at law. I will promptly inform the insurance carrier in writing if anything happens before my coverage takes effect that makes an answer on

this application incomplete or incorrect. Following receipt of a fully-executed application, coverage will be in force as of the effective date determined by the

insurance carrier under applicable law.

STATEMENT OF UNDERSTANDING

SECTION 9

By signing this application, I represent that all my answers are complete and accurate and that I understand and agree to the following conditions:



No independent producer, agent or employee of the insurance carrier, or of my employer, can change any part of this application or waive the requirement

that I answer all questions completely and accurately.



The insurance carrier may terminate or rescind an employer’s group coverage for any intentional misrepresentation, omission of fact by, concerning, or on

behalf of any applicant that was or would have been material to the insurance carrier’s acceptance of a risk, extension of coverage, provision of benefits or

payment of any claim.



As proof of status of employment, I authorize my employer to release to the insurance carrier appropriate documents, including but not limited to W-2 Wage

and Tax Statements and other wage and tax summaries or forms.



Coverage for me and any eligible persons named on this application will begin on the effective date pursuant to the terms of the plan/contract.



I agree to abide by the terms of the group’s master policy/member certificate, which sets forth all of the terms and conditions of my coverage. No agent or

other person can change the terms of the master contract, any of its amendments, or this application, except with an amendment issued expressly for that

purpose and signed by an authorized officer of the insurance carrier.



I have reviewed all answers given on this application and, regardless of whether an independent producer or other person has filled out the answers for me,

I verify that the answers are true and complete.

PREEXISTING CONDITION WAITING PERIOD

SECTION 10

NOTICE OF PREEXISTING CONDITION LANGUAGE: I understand that, until the first plan year beginning January 1, 2014 or later, a waiting period for

preexisting conditions may apply. This means that if you have a medical condition before coming to our plan, you might have to wait a specified period of time

before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care or treatment was

recommended or received within a six-month period. Generally, this six-month period ends the day before your coverage becomes effective. However, if you

were in a waiting period for coverage, the six-month period begins on the day before the waiting period began. This preexisting condition exclusion does not

apply to pregnancy nor to individuals under the age of 19 years beginning upon the Employer Group renewal on or after September 23, 2010, as provided in the

Patient Protections and Affordable Care Act (PPACA).

This exclusion may last up to 12 months from your first day of coverage or, if you were in a waiting period, from the first day of your waiting period. However, you

can reduce the length of this exclusion period by the number of days of your prior “creditable coverage.” Most prior health coverage is considered creditable

coverage and can be used to reduce the preexisting condition exclusion if you have not experienced a break in coverage of at least 63 days.

SECTION 11

ACKNOWLEDGEMENT

I acknowledge and understand my health plan may request or disclose health information about me or my dependents (persons who are eligible for benefits

coverage and are listed on the enrollment form) for the purpose of facilitating health care treatment, payment or for the purpose of business operations necessary

to administer health care benefits; or as required by law.

Health information requested or disclosed may be related to treatment or services performed by:



A physician, dentist, pharmacist or other physical or behavioral health care practitioner;



A clinic, hospital, long-term care or other medical facility;



Any other institution providing care, treatment, consultation, pharmaceuticals or supplies or;



An insurance carrier or group health plan.

Health information requested or disclosed may include, but is not limited to: claims records, correspondence, medical records, billing statements, diagnostic

imaging reports, laboratory reports, dental records, or hospital records (including nursing records and progress notes).

This acknowledgement does not apply to obtaining information regarding psychotherapy notes. A separate authorization will be used for psychotherapy notes.

(mm/dd/yyyy)

Signature of Employee _______________________________________________________

Date

___________________________

(mm/dd/yyyy)

Signature of Spouse _________________________________________________________

Date

___________________________

(mm/dd/yyyy)

(if applying for coverage)

FOR OFFICE USE ONLY

Electronic System ID