Healthcare Supplemental Plan Application

Healthcare Supplemental Plan Application

Applicant Name:   Date of Birth:   Gender: Male  Female  Other

Applicant Information

Employer / Group Information

Plan Selection

Select the supplemental plan(s) for which you are applying (check all that apply):

Accident Insurance
Critical Illness
Hospital Indemnity
Dental
Vision
Other (specify below)

Existing Coverage

Do you currently have health or supplemental coverage from any insurer?   Yes   No

Dependents to be Covered

List spouse and/or dependent children to be included under this application (if none, leave blank):

Medical & Health History

To the best of your knowledge, answer the following. Failure to disclose material medical history may result in denial or rescission of coverage.

In the past 12 months, have you been treated for, diagnosed with, or had symptoms of any condition requiring medical attention?   Yes   No

Have you used tobacco or nicotine products within the past 12 months?   Yes   No

Authorization, Acknowledgment and Certification

I certify that the statements and answers on this application are complete and true to the best of my knowledge. I understand that any material misrepresentation, omission or concealment of fact may be grounds for denial of benefits or rescission of coverage. I authorize any physician, medical practitioner, hospital, clinic, or other medical or medically related facility, insurance company, or other organization, institution or person that has any records or knowledge of me or my health to disclose such information to the insurer to which this application is submitted and its representatives for purposes of underwriting, claims administration, or eligibility determination.

I understand that this authorization permits the release of medical information relating to mental health conditions, substance use disorders, and HIV/AIDS where permitted by law. I further authorize the insurer to obtain consumer reports and to verify other information provided on this application. A photocopy or electronic reproduction of this authorization shall be as valid as the original. This authorization will remain in effect until unless sooner revoked in writing.

I acknowledge receipt of the insurer's privacy practices and authorize the insurer and its designees to use and disclose protected health information as necessary to process this application and any resulting claim. I understand that coverage is subject to eligibility, plan provisions, waiting periods, and any pre-existing condition limitations described in the plan documents.

By signing below I affirm that I have read and understand the statements above and that I am authorized to make this application. I understand that this application, together with any required premium, constitutes a request for coverage and does not guarantee acceptance. The insurer may request further information or medical records prior to making an underwriting decision.

Privacy & HIPAA Acknowledgement

I acknowledge that I have been provided a copy of the privacy practices and understand that my protected health information will be handled in accordance with applicable law. I consent to communications and disclosures as described in the privacy notice.

I acknowledge and consent to the privacy practices described above.

Additional Declarations

I understand that the insurer may, at its discretion, request examination by a physician designated by the insurer and that any such examination or records requested are for underwriting purposes only. I consent to such examinations and to the release of records to the insurer for the purpose of underwriting or claim evaluation.

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