Nongroup Enrollment/change Request Form (Page 5 of 7) in pdf

[E. Preexisting Conditions – Check all that apply. If you check one of the conditions in #1, or respond yes to any question in #2, give details on a separate sheet of paper. This

separate sheet must be signed and dated by you. This information may ONLY be used to determine if a condition is a pre-existing condition. You CANNOT be denied coverage

under a health benefits plan on the basis of accurate responses to the following questions. Carriers may only use the information to expedite the processing of claims.]

[1. If you or any dependent to be covered has been diagnosed as having any of the following

[2. During the past 6 months, have you or any dependent to be

[Yes No]

within the past 6 months, please place a check mark in the appropriate box:]

covered:]

[

a. Alcoholism or Drug Abuse

i. High Blood Pressure

[a. been examined or treated by a physician or other health care

[

b. Arthritis

j. Kidney or Liver Disorder

provider for any condition, illness or injury, other than as stated

c. Blood Disorder

k. Lung or Respiratory Disorder

above?

d. Back or Neck Disorder, Injury or Pain

l. Mental or Nervous Disorder

b. been advised to have treatment or surgery or testing that has not

e. Cancer or Tumors

m. Paralysis, Stroke or Epilepsy

been done?

f. Diabetes

n. Does a pregnancy exist?

c. been admitted to a hospital or other health care facility as an

g. Gastro or Intestinal Disorder

If so, provide expected due date:

inpatient?

h. Heart Disorder/Condition /Chest Pain

__________________________]

d. taken prescribed medication?]

]

1. Employer Name:________________________________________________________________________________

[F.] Additional Spouse/Domestic Partner/Civil

Union Partner Information – If not applicable,

Employer Address:______________________________________________________________________________

please mark as “NA.”

City, State, Zip Code:____________________________________________________________________________

Employer Phone: (

)

2a.

2b. Please explain why the address is different:

Street/Apt:______________________________________________________________________________________

_____________________________________________

Street/Apt:______________________________________________________________________________________

_____________________________________________

City, State, Zip Code:

[G.] Additional Child Information – Provide information below about children listed in Section D, if they have a different address. If multiple children are at an address, you may

list them together. Attach additional pages as necessary, signed and dated.

Name(s):________________________________________________________________

Name(s):_______________________________________________________________

Street/Apt:_______________________________________________________________

Street/Apt:_____________________________________________________________

Street/Apt:_______________________________________________________________

Street/Apt:_____________________________________________________________

City, State, Zip Code: _____________________________________________________

City, State, Zip Code:_____________________________________________________

Reason:_________________________________________________________________

Reason:________________________________________________________________

[H.] Race/Ethnicity – Response is

Choose a category that most closely describes you:

American Indian or Alaskan Native

Black, not of Hispanic origin

Hispanic

appreciated but NOT required!

Asian or Pacific Islander

White, not of Hispanic origin

Payment Information –

[I.]

[

Monthly

Check

[

Credit Card Type (AMEX, Visa, etc.):_____________________

indicate how you would like to [be

[

Quarterly]

Money Order

No.:___________________________ Exp. Date: ____/____/____

billed and] make payment

[

Semi-annually]] [

Automatic Bank Draft (attach voided check)] Cardholder Name:

[J.] [Applicant’s] Signature

I represent that all the information supplied in this application is true and complete. I hereby agree to the Conditions of Enrollment set forth in this

Enrollment/Change Request form. I authorize deductions from my earnings for any contributions required from me.

Signature:

Date:

[K.] Broker/General Agent

Signature of Preparer

Date

NJ Producer License #

Signature

General Agent

Agent ID #

NJ-HINT-Individual

[Internal Carrier Form Number]