Group Coverage Application Form Page 2
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4C
DECLARATION
By signing the section H of the application, I elect coverage under the plan specified in section A of the form and for the persons list-
ed there, and agree to abide by the conditions of the agreement and pay required premiums for the plan as selected. I here-
by authorize any licensed physician, medical or medically related facility, insurance company, or other organization or person or
institution that has any records concerning my health or the health of any covered family member to forward such information to Independence
Blue Cross and Highmark Blue Shield. This application is subject to acceptance and to the waiting periods, exclusions, and all other provisions
contained in the agreement between my Employer, Association, or Welfare board and Independence Blue Cross and Highmark Blue Shield.
D
NOTICE REGARDING FRAUDULENT INFORMATION
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.
E
GENERAL INFORMATION
Various Medicare Secondary Payer (MSP) laws place responsibilities on certain employers that may affect the rights of employees, retirees,
and/or their dependents who are eligible for Medicare. These MSP laws, in general, speak of certain persons who are age 65 or older, of
certain persons who are disabled, and of certain persons who suffer from end-stage renal disease. If you have any questions about the
MSP laws, please contact your employer.
F
PLEASE ANSWER THE FOLLOWING QUESTIONS
If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you are eligible for guar-
anteed issue of a Medicare supplement insurance policy, or that you have certain rights to buy such a policy, you may be guaranteed
acceptance in one of our Medicare supplement plans. Please include a copy of the notice from your prior insurer with your applica-
tion. PLEASE ANSWER ALL QUESTIONS.
Please mark Yes or No below with an X.
To the best of your knowledge:
1. Did you turn age 65 in the last 6 months? .............................................................................................................
Yes
No
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2. Did you enroll in Medicare Part B in the last 6 months? .......................................................................................
Yes
No
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If yes, what is the effective date? .......................................
MM
DD
YYYY
3. Are you covered for medical assistance through the state Medicaid program? .....................................................
Yes
No
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NOTE TO APPLICANT: If you are participating in a “Spend-Down Program” and have not
met your “Share of Cost,” please answer NO to this question.
If yes, will Medicaid pay your premiums for this Medicare supplement policy? .............................................
Yes
No
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Do you receive any benefits from Medicaid OTHER THAN payments towards your
Medicare Part B premium? ............................................................................................................................
Yes
No
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4. Are you enrolled in PACE (Pennsylvania Pharmaceutical Assistance Contract for the Elderly)? ............................
Yes
No
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5. If you had coverage from any Medicare plan other than Original Medicare within the last 63 days (for example, a Medicare
Advantage plan, or a Medicare HMO or PPO), fill in your start and end dates below. If you are still covered under this plan,
leave “END” blank.
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START
END
MM
DD
YYYY
MM
DD
YYYY
If you are still covered under the Medicare plan, do you intend to replace your
current coverage with this new Medicare supplement policy? .......................................................................
Yes
No
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Was this your first time in this type of Medicare plan? ..................................................................................
Yes
No
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Did you drop a Medicare supplement policy to enroll in the Medicare Plan? ..................................................
Yes
No
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6. Do you have another Medicare supplement policy in force? ..................................................................................
Yes
No
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If yes, with what company and what plan do you have? ______________________________________________
If yes, do you intend to replace your current Medicare supplement policy with this policy? .............................
Yes
No
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