Form Ms-07-422 - Addition/termination Change (Page 4 of 4) in pdf

Form Ms-07-422 - Addition/termination Change Page 4

{For applicants in Ohio:

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim

containing a false or deceptive statement is guilty of insurance fraud.}

{For applicants in Oklahoma:

Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an

insurance policy containing any false, incomplete or misleading information is guilty of a felony.}

{For applicants in Oregon:

Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.}

{For applicants in the state of Pennsylvania:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or

statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any

fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.}

{For applicants in all other states:

It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding

the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.}

{For applicants in Florida:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application

containing any false, incomplete, or misleading information is guilty of a felony of the third degree.}

Employee/Applicant Signature:

Date:

To Be Completed by Employer

Class Code:

Enrollee Effective Date:

Employer Name:

Policy Number:

Plan Variation/

Enrollment:

Date of Hire:

Plan Code:

Reporting Code:

New Hire

Other

Employer Authorization:

Group vision care insurance products are underwritten or provided by: United HealthCare Insurance Company, Hartford,

Connecticut.

V-ENROLL-ER (11/2008)

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Form Ms-07-422 - Addition/termination Change Page 4