Form 5217ut - Utah Universal Small Employer Application

UTAH SMALL EMPLOYER HEALTH INSURANCE APPLICATION

OFFICE USE ONLY

REASON FOR ENROLLMENT (mark all that apply)

Policy / Group No.

 New Group

 Newborn

 Loss of Coverage____________________

(mm/dd/yyyy)

 Open Enrollment  Court Order

 Marriage____________________

(mm/dd/yyyy)

Effective Date

 New Hire

 Dependent Addition

 Divorce_____________________

(mm/dd/yyyy)

 New Application  Other:___________

 Military Leave of Absence(USERRA)________

(mm/dd/yyyy)

PEC

 COBRA

 Utah mini-COBRA

Alternative Coverage (Utah NetCare) for:

 Employee  Dependent(s)

New Hire Waiting Period

Length of continuation coverage: 12 mos. 18 mos. 36 mos. Other:

Original Qualifying Event Date:

Qualifying Event Date:

Date of Event:

(mm/dd/yyyy)

 WAIVER OF COVERAGE Individuals waiving coverage complete only Section J.

A. EMPLOYER INFORMATION

(mm/dd/yyyy)

Employer

Hire Date

Rehire Date

Location

Is this a division?  Yes  No If “Yes,” name of parent company

B. EMPLOYEE INFORMATION

Name (Last)

(First)

(MI)

Job Title

Hrs/Week

Marital Status

 Married  Single

 Divorced

 Widowed

 Domestic Partner*

Address

Apt.

City

State

Zip

State

xxxxx-xxxx

Email address

Home (or other) Phone (

)

Business Phone (

)

Email Address:

(xxx) xxx-xxxx

Spouse’s Employer

Spouse’s Business (or other) Phone (

)

(xxx) xxx-xxxx

C. ENROLLING EMPLOYEE / SPOUSE / DOMESTIC PARTNER* / DEPENDENTS

List yourself and all dependents applying for coverage. Attach a separate sheet if necessary.

Name

Social Security #

Date of Birth

Age

Gender

Weight

Height

(Last, First, Middle)

(for insurer use only)

MM/DD/YYYY

Employee

 Male

x lbs

Xft Xin

(mm/dd/yyyy)

 Female

lbs.

Spouse/

 Male

x lbs Xft Xin

(mm/dd/yyyy)

Domestic Partner*

 Female

lbs.

Dependent

 Male

x lbs Xft Xin

(mm/dd/yyyy)

 Female

lbs.

Dependent

 Male

x lbs Xft Xin

(mm/dd/yyyy)

 Female

lbs.

Dependent

 Male

x lbs Xft Xin

(mm/dd/yyyy)

 Female

lbs.

D. CURRENT/PRIOR COVERAGE INFORMATION

Indicate any health care coverage, Medicaid, or Medicare in effect within the last 24 months. This will be used to determine if you have creditable coverage or if

benefits will be coordinated. If no health care coverage was in effect within the past 24 months, indicate NONE. If applicable, provide a copy of any applicable court

documentation that shows who is responsible for the dependent(s)’ health care coverage. Attach a separate sheet if necessary.

Will

Type of Coverage

Date of Coverage

Insurer (Including policyholder name,

coverage

(Check all that apply)

MM/YYYY

insurer name and phone number) Medicaid or Medicare

continue?

Start Date

End Date

Employee:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

Spouse/Domestic Partner*:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

Dependent:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

Dependent:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

Dependent:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

*Check with your employer to determine if domestic partner coverage is available.

Page 1 of 4

Utah Small Employer Health Insurance Application October 2010

Form 5217UT (Rev. 10/10)

Form 5217ut - Utah Universal Small Employer Application - Best Life

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