Foundation Payroll Deduction Authorization Medical Mutual
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4Please return form to
Attn: Membership Department
Medical Mutual
2060 East Ninth St.
Cleveland, OH 44115-1355
MEDICAL MUTUAL AND ITS FAMILY OF COMPANIES
REQUEST TO EXTEND LIMITING AGE FOR DEPENDENT CHILD
To the Policyholder:
Your certificate (or benefit booklet) provides that coverage for certain Dependents may continue beyond the limiting age specified in your
Schedule of Benefits. The information requested on this application allows Medical Mutual to administer this provision. The Policyholder must
complete each question in Section 1, and the Dependent's Attending Physician must complete each question in Section 2. Please return this
application to Medical Mutual, Attention: Membership Department, 2060 East 9th St., Cleveland, OH 44115, Mailzone 01-6B-6200.
SECTION 1 – TO BE COMPLETED BY POLICYHOLDER
Policyholder's Name
Certificate #
Group #
Name of Group
Dependent's Name
Sex
Birthday
□
Month/Day/Year
Male
Female □
/
/
Policyholder's Address (number, street, city, state & zip code)
Relationship of Dependent to Policyholder
Does Dependent Have a Legal Guardian?
Yes □
No □
Is Dependent
Is Dependent Mentally
Is Dependent Physically or Mentally Disabled?
Date of Onset of Dependent’s
Married?
Disabled?
Condition:
Yes □
No □
If Yes, What is the disability?
Yes □
No □
Yes □
No □
IQ _______________
Does Dependent receive SSI
Is Dependent Incapable of Self-Sustaining
Was Dependent Listed on Your Last Income Tax
or Medicare? If yes, provide
Employment?
Return?
documentation.
Yes □
No □
Yes □
No □
Yes □
No □
Do you Support the Dependent?
If “Yes”, What Part of Support Do You Contribute?
Is Dependent Employed Now?
Yes □
No □
Yes □
No □
(% of total)
Yes □
No □
Was Dependent Ever Employed?
Type of Work Done:
____________________________________________________________
Give Name(s) of Employer(s)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Hours Worked Per Week:
Ambulate? Yes □
No □
Speak? Yes □
No □
Feed Self? Yes □
No □
Is Dependent Able to:
Yes □
No □
Write? Yes □
No □
Bathe self? Yes □
No □
Read?
Can Dependent Be Left Alone? Yes □
No □
Who Does Dependent Live With? ______________________________________________
Past Vocational Training: _______________________________________________
Level of Education:_________________________________
At What Age or Grade Level Dependent Functions: __________ years / grade level (circle one)
Self Care Skills: ___________________________________________________________________________________________________________
General Physical Capabilities: ________________________________________________________________________________________________
Disabilities _______________________________________________________________________________________________________________
Communication Skills: ______________________________________________________________________________________________________
Why Dependent is Unable to Work - Attach documentation of pertinent info such as school records, etc.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Yes □
No □
Is Dependent Covered Under Any Other Group Medical Insurance or Pre-payment Program?
If Yes, Identify The Other
Insurance Carrier ________________________________________ Policy Number_________________ Policyholder__________________________
I CERTIFY THAT INFORMATION PROVIDED ON THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND
AUTHORIZE RELEASE OF ANY INFORMATION REQUESTED WITH RESPECT TO THIS CERTIFICATION.
________________________________________________________
_________________________
Signature of Policyholder
Date
For an explanation of the law, see the reverse side of the form.
Z5185 R8/11
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