Illinois Standard Health Application

Illinois Standard Health Employee Application for Small Employers

For assistance in completing this application, please contact your employer or insurance agent. For information about your health insurance rights under state and federal law, and other resources, please contact the Illinois Department of Insurance’s Office of Consumer Health Insurance toll free at (877) 527-9431.

This standard application is intended to simplify your health insurance application process. You will only need to complete this one application, even when your employer has requested quotes from multiple insurance companies.

The information you provide in this application will be sent to the following insurance companies:

(To be completed by employer)

TO BE COMPLETED BY EMPLOYER

Employer Name: Phone #:

Address:

Reason for Enrollment (Mark all that apply)

New Enrollment: New Group Open Enrollment New Hire (Date: ) Late Enrollee

Special Enrollment: Adoption Court Order Dependent Addition Divorce Domestic Partner Loss of Coverage Marriage Newborn Other Date of Event:

Employment Status: Active Retiree (Retirement Date: ) Illinois Continuation COBRA

Coverage Applies To: Employee Dependent

Qualifying Event:

Start Date: Projected End Date:

A Employee Information

Name (Last): (First): (MI):

Job Title: Hire Date: Hrs/Week:

Marital Status: Married Single Divorced Widowed Domestic Partner

Home Address: Apt #:

City: State: Zip:

Home (or Cell) Phone: Business Phone:

Email Address (optional):

B Coverage Requested

Medical

Employee: Yes No Plan Choice:

Spouse/Domestic Partner: Yes No Plan Choice:

Child(ren): Yes No Plan Choice:

If you are waiving (declining) coverage for yourself or any member of your family, you must complete Section C below.

C Waiver of Coverage

Please complete this section only if you are waiving (declining) coverage for yourself or one or more of your family members.

I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer.

I understand and agree:

If I am declining coverage for myself, my spouse/domestic partner, or my dependent child(ren) because of other coverage, I may in the future be able to enroll myself, my spouse/domestic partner, or my dependent child(ren) provided that I request enrollment within 31 days after the other coverage ends.

If I have a new spouse/domestic partner or child as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my new spouse/domestic partner or child provided that I request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

If I decide to request coverage in the future, for a reason other than the termination of other coverage or the addition of a new spouse/domestic partner or child, I may be considered a late enrollee, if applicable, or I may have to wait until the plan’s next open enrollment period. I also understand that as a late enrollee, coverage for preexisting conditions may be excluded for up to a period of 18 months. This period may be offset by the time I, my spouse/domestic partner, or my dependent child(ren) was covered under a qualified health plan.

I certify that I was not pressured, forced, or unfairly induced by my employer, the agent, or the insurer(s) into waiving or declining the group coverage.

I DO NOT want, and hereby waive, coverage for (initial next to all that apply):

Medical for Myself My Spouse/Domestic Partner My Dependent Child(ren)

Dental Myself My Spouse/Domestic Partner My Dependent Child(ren)

Vision Myself My Spouse/Domestic Partner My Dependent Child(ren)

Basic Life Myself My Spouse/Domestic Partner My Dependent Child(ren)

Dependent Life Myself My Spouse/Domestic Partner My Dependent Child(ren)

Voluntary Life Myself My Spouse/Domestic Partner My Dependent Child(ren)

Short-Term Disability Myself My Spouse/Domestic Partner My Dependent Child(ren)

Long-Term Disability Myself My Spouse/Domestic Partner My Dependent Child(ren)

I am declining group coverage for the following reason(s): Spouse/Domestic Partner’s Employer Plan Individual Coverage (Non-Group Plan) COBRA/State Continuation Medicare or other Government Program Other (please explain):

If you are declining ALL coverage for ALL persons, please skip to the Acknowledgement & Signature section on page 10 of this application.

D Individuals Requesting Coverage

List yourself and all eligible family members to be included under coverage.

Dependent Name (Last): (First): (MI):

Social Security Number: Date of Birth:

Weight: Height: Gender: Male Female

Eligible Military Veteran: Yes No

HMO only (if/when applicable): Primary Care Physician: Physician ID:

E Current/Prior Coverage Information

Please indicate for EACH person listed on this application any health coverage, including Medicare or Medicaid, in effect within 24 months prior to the proposed effective date of this coverage.

Employee Name (Last): (First): (MI):

Current/Most Recent Coverage: Group Medical Dental Individual Medical None

Dates of Coverage: From: To:

Policyholder Name: Insurer Name:

Will the individual continue this coverage? Yes No

F Health Statement

Instructions:

1. The information you provide in this application is confidential.
2. The health information you provide below will be used by the insurance company to determine pricing and pre-existing condition waiting periods.
3. Each medical question below applies to all persons requesting coverage.
4. Answer the questions below with either Yes or No.
5. Do not leave any question unmarked.
6. Neither your employer nor your insurance agent can waive these requirements.
7. After you submit this application, the insurance company may call you for additional information.

1. For the following conditions, within the past 5 years, have you or any dependents for whom you are requesting coverage:

A. Cardiovascular disease or heart attack, stroke, high blood pressure, or any other disease or disorder of the heart, arteries, blood, or blood vessels? Yes No

B. Cancer or cancerous tumor? Yes No

C. Asthma, emphysema, tuberculosis, or any other disorder of the lungs or respiratory system? Yes No

D. Diabetes? If yes, check all that apply: Yes No Non-Insulin Dependent Insulin Dependent Insulin Pump

E. Hepatitis, or any disorder of the liver, stomach, colon, or intestines? Yes No

F. Growth disorder or a disorder of the pancreas? Yes No

G. Chronic kidney stones, or other disorders of the kidney, prostate, or bladder? Yes No

H. Reproductive organ disorders or infertility? Yes No

I. Arthritis, or any other disorder of the joints, muscles, back, or bones? Yes No

J. Mental or emotional disorder? Yes No

K. Seizures/epilepsy, paralysis, or any other disorder of the brain or nervous system? Yes No

L. HIV positive, AIDS, diseases associated with AIDS, lupus, or other disorder of the immune system? Yes No

M. Alcohol, drug, or substance use or dependency? Yes No

N. Organ or bone marrow transplant? Yes No

2. Are you, your spouse/domestic partner, or any dependent for whom you are requesting coverage currently pregnant? Yes No

Due Date: If yes, are multiples expected? Yes No Are there any known complications, or is a cesarean section planned? Yes No

3. Within the past 12 months, have you or your spouse/domestic partner used any tobacco products? Employee: Yes No Spouse/Domestic Partner: Yes No

4. Within the past 12 months, has any applicant been prescribed medication that is not indicated elsewhere in this application? Yes No

5. Within the past 5 years, has any person applying for coverage been tested for or diagnosed with, had medical treatment recommended, received medical treatment, including prescription medications, or been hospitalized for any illness, injury or health condition not indicated above? Yes No

G Additional Information

If you answered “Yes” to any of the questions above, you must complete this section.

Question Number: Name of Individual:

Condition/Diagnosis: Date Diagnosed (MM/YYYY):

Treatment Received:

Treatment ongoing? Yes No Last Treatment Date:

Surgery, additional tests or treatment recommended?

Medication Prescribed (if any): Currently taking medication? Yes No

H Additional Coverage Options

You should complete this section only if your employer offers any of the additional coverage options below.

Employee

Dental: PPO HMO Dental HMO Office ID #:

Vision Basic Life Dependent Life Voluntary Life: Amount (if applicable): $

Short-Term Disability Long-Term Disability

Employee Class:

Salary (if requesting life or disability coverage): $ Hourly Weekly Monthly Semi-monthly Annually

Spouse/Domestic Partner

Dental: PPO HMO Dental HMO Office ID #:

Vision Basic Life Dependent Life Voluntary Life: Amount (if applicable): $

Short-Term Disability Long-Term Disability

Child(ren)

Dental: PPO HMO Dental HMO Office ID #:

Vision Basic Life Dependent Life Voluntary Life: Amount (if applicable): $

Short-Term Disability Long-Term Disability

Beneficiary Information (if requesting life insurance)

Primary Beneficiary Name (Last, First, MI): Relationship: Benefit %:

Secondary Beneficiary Name (Last, First, MI): Relationship: Benefit %:

Acknowledgement & Signature

I understand, agree, and represent that:

I have read this document or it has been read to me.

The answers provided within this entire application for coverage are, to the best of my knowledge and belief, true and complete.

Neither my employer nor the agent has the authority to waive a complete answer to any question, determine coverage or insurability, alter any contract, or waive any of the insurance carrier’s other rights and requirements.

I understand that if I intentionally omit or provide false information on or in relation to this application, then this policy may be cancelled retroactively.

If this application for coverage is accepted, coverage will be effective on the date specified by the insurance carrier on the certificate of coverage/certificate of insurance.

I hereby enroll for benefits as indicated in Section B and Section H of this application.

I understand that the information I have provided in this application will be used to make decisions regarding eligibility, enrollment, underwriting, and premium risk rating.

I authorize the insurance carrier to electronically transmit the information contained herein.

By signing below, I acknowledge that I have read and understand this document and I am signing of my own free will.

For assistance in completing this application, please contact your employer or insurance agent. For information about your health care rights under state and federal law, and other resources, please contact the Illinois Department of Insurance’s Office of Consumer Health Insurance toll free at (877) 527-9431.