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.
INSURER USE ONLY
Policy/Group No.
Section No.
Effective Date
New Hire Waiting Period
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)
Insurer:
Insurer:
Insurer:
Insurer:
Insurer:
Insurer:
TO BE COMPLETED BY EMPLOYER
Employer Name:
Phone #:
Address:
R e a s o n f o r E n r o l l m e n t (Mark all that apply)
New Enrollment:
New Group
Special Enrollment:
Adoption
Court Order
Loss of Coverage
Employment Status:
Active
New Hire (Date:
Open Enrollment
Dependent Addition
Marriage
Newborn
Retiree (Retirement Date:
Illinois Continuation
Employee
)
Divorce
/
Domestic Partner
Date of Event:
Other
Late Enrollee
/
/
)
/
COBRA
Dependent
Qualifying Event:
Start Date
A
/
/
Projected End Date
/
/
Employee Information
(First)
Name (Last)
Job Title:
(MI)
Hire Date:
Marital Status:
Married
Single
Divorced
Widowed
Hrs/Week:
Domestic Partner
Home Address:
Apt #:
City:
State:
Home (or Cell) Phone: (
)
Zip:
Business Phone: (
)
Email Address (optional):
B
Coverage Requested
Medical
Employee:
Yes
Plan Choice:
No
Spouse/Domestic Partner:
Plan Choice:
Yes
No
Child(ren):
Yes
No
Plan Choice:
If you are w a i v i n g ( d e c l i n i n g ) coverage for yourself or any member of your family, you must complete Section C
below.
GR-67834-49 (1-11)
Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
(V1) IL R-POD A
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
C
Employee Name
Waiver of Coverage
Please complete this section only if y o u a r e w a i v i n g ( d e c l i n i n g ) c o v e r a g e 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 D O N O T want, and hereby waive, coverage for (i n i t i a l next to all that apply):
Medical for
[
] Myself [
] My Spouse/Domestic Partner [
] My Dependent Child(ren)
Dental ✶ for
[
] Myself [
] My Spouse/Domestic Partner [
] My Dependent Child(ren)
[
] Myself [
] My Spouse/Domestic Partner [
] My Dependent Child(ren)
Basic Life ✶ for
[
] Myself [
] My Spouse/Domestic Partner [
] My Dependent Child(ren)
Dependent Life ✶ for
[
] Myself [
] My Spouse/Domestic Partner [
] My Dependent Child(ren)
[
] Myself [
] My Spouse/Domestic Partner [
] My Dependent Child(ren)
for
[
] Myself [
] My Spouse/Domestic Partner [
] My Dependent Child(ren)
for
[
] Myself [
] My Spouse/Domestic Partner [
] My Dependent Child(ren)
Vision
✶
for
Voluntary Life ✶ for
Short - Term Disability
Long - Term Disability
✶
✶
✶ If offered.
I am d e c l i n i n g group coverage for the following reason(s): (check all that apply)
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.
(V1)
GR-67834-49 (1-11)
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Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
D
Employee Name
Individuals Requesting Coverage
List yourself and all eligible family members to be included under coverage.
Please check with your employer or insurance agent about who may qualify as an eligible family member under the
policy.
Illinois’ Young Adult Dependent Coverage law allows parents to cover children up to the age of 26, and up to age 30
for military veteran dependents, regardless of whether the child may be considered a dependent for tax or other
purposes. For more information, please visit the Illinois Department of Insurance website at
www.insurance.illinois.gov.
H
N o t e : For purposes of this application, an “eligible military veteran” is a veteran who served in the active or reserve
components of the U.S. Armed Forces, including the National Guard, and who received a release or discharge other
than a dishonorable discharge.
If additional space is required, please attach a separ ate sheet and be sure to sign and date that sheet.
E m p l o y e e N a m e (Last)
(First)
Social Security Number:
Weight:
HMO only
Date of Birth:
lbs.
(if/when applicable):
Height:
ft.
in.
(if/when applicable):
Height:
ft.
in.
Male
Female
Physician ID:
(MI)
Date of Birth:
lbs.
Eligible Military Veteran:
Yes
(if/when applicable):
Height:
ft.
in.
Gender:
/
/
Male
Female
No
Primary Care Physician:
Physician ID:
Dependent N a m e (Last)
(First)
Social Security Number:
(MI)
Date of Birth:
Weight:
lbs.
Eligible Military Veteran:
Yes
(if/when applicable):
Height:
ft.
in.
Gender:
/
/
Male
Female
No
Primary Care Physician:
Physician ID:
Dependent N a m e (Last)
(First)
Social Security Number:
(MI)
Date of Birth:
Weight:
lbs.
Eligible Military Veteran:
Yes
(if/when applicable):
GR-67834-49 (1-11)
/
/
(First)
Weight:
HMO only
(MI)
Gender:
Primary Care Physician:
Social Security Number:
HMO only
Female
(First)
Dependent N a m e (Last)
HMO only
Male
Date of Birth:
lbs.
/
/
Physician ID:
Social Security Number:
HMO only
Gender:
Primary Care Physician:
S p o u s e / D o m e s t i c P a r t n e r N a m e (Last)
Weight:
(MI)
Height:
ft.
in.
Gender:
/
/
Male
Female
No
Primary Care Physician:
Physician ID:
3
(V1)
Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
Employee Name
Dependent N a m e (Last)
(First)
Social Security Number:
Date of Birth:
Weight:
lbs.
Eligible Military Veteran:
Yes
HMO only
E
(MI)
(if/when applicable):
Height:
ft.
in.
Gender:
/
/
Male
Female
No
Primary Care Physician:
Physician ID:
Current/Prior Coverage Information
Please indicate for EACH person listed on this application any health coverage, including Medicare or Medicaid, in
effect within 2 4 m o n t h s prior to the proposed effective date of this coverage. Each person applying for coverage must
be listed below. If no health care coverage was in effect within the p a s t 2 4 m o n t h s , please indicate NONE . If
coverage is provided for a dependent from a previous marriage or relationship, please attach a copy of the court
documentation showing who is responsible for the dependent(s)’ health care coverage so that the insurer can determine
whose coverage is primary.
N o t e : If you have had health care coverage within the last 63 days, your Pre-Existing Condition (PEC) waiting
period limitation may be partially or completely waived. To determine if this applies to you, you must provide proof of
prior coverage, such as a Certificate of Creditable Coverage from your previous insurer. Submission of prior coverage
information does not automatically waive any PEC limitation. You will be subject to an automatic PEC Waiting Period of
up to 12 months until the insurer receives evidence of prior coverage.
U
U
If additional space is required, please attach a separate sheet and be sure to sign and date that sheet.
E m p l o y e e N a m e (Last)
(First)
(MI)
Current/Most Recent Coverage:
Group Medical
Dates of Coverage: From:
/_
/_
Policyholder Name:
Will the individual continue this coverage? Yes
No
Dental
Individual Medical
To:
/_
/_
Insurer Name:
Prior Coverage (if any):
Dates of Coverage: From:
Policyholder Name:
Individual Medical
To:
/_
Insurer Name:
Group Medical
/_
Dental
/_
S p o u s e / D o m e s t i c P a r t n e r N a m e (Last)
None
/_
(First)
(MI)
Current/Most Recent Coverage:
Group Medical
Dates of Coverage: From:
/_
/_
Policyholder Name:
Will the individual continue this coverage? Yes
No
Dental
Individual Medical
To:
/_
/_
Insurer Name:
Prior Coverage (if any):
Dates of Coverage: From:
Policyholder Name:
Individual Medical
To:
/_
Insurer Name:
Group Medical
/_
Dental
/_
Dependent N a m e (Last)
None
None
/_
(First)
(MI)
Current/Most Recent Coverage:
Group Medical
Dates of Coverage: From:
/_
/_
Policyholder Name:
Will the individual continue this coverage? Yes No
Dental
Individual Medical
To:
/_
/_
Insurer Name:
Prior Coverage (if any):
Dates of Coverage: From:
Policyholder Name:
Individual Medical
To:
/_
Insurer Name:
GR-67834-49 (1-11)
None
Group Medical
/_
Dental
/_
4
None
None
/_
(V1)
Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
Employee Name
Dependent N a m e (Last)
(First)
Current/Most Recent Coverage:
Dates of Coverage: From:
Group Medical
/_
Dental
/_
/_
Group Medical
/_
Individual Medical
To:
/_
None
/_
No
Dental
/_
Insurer Name:
Dependent N a m e (Last)
(First)
Current/Most Recent Coverage:
Dates of Coverage: From:
Group Medical
/_
Dental
/_
(MI)
Individual Medical
/_
Individual Medical
To:
/_
None
/_
None
/_
To:
Insurer Name:
Policyholder Name:
Will the individual continue this coverage?
Yes
Group Medical
/_
No
Dental
/_
Insurer Name:
Policyholder Name:
Dependent N a m e (Last)
(First)
Current/Most Recent Coverage:
Dates of Coverage: From:
Group Medical
/_
Dental
/_
(MI)
Individual Medical
/_
Individual Medical
To:
/_
None
/_
None
/_
To:
Insurer Name:
Policyholder Name:
Will the individual continue this coverage?
Prior Coverage (if any):
Dates of Coverage: From:
/_
None
Insurer Name:
Yes
Policyholder Name:
Prior Coverage (if any):
Dates of Coverage: From:
Individual Medical
To:
Policyholder Name:
Will the individual continue this coverage?
Prior Coverage (if any):
Dates of Coverage: From:
(MI)
Yes
Group Medical
/_
No
Dental
/_
Insurer Name:
Policyholder Name:
Medicare : If you or any family members listed on this application have Medicare coverage, please
complete the following information.
E n r o l l i n g I n d i v i d u a l N a m e (Last)
Medicare
Part A
Part B
Part D
Effective Date:
/_
/_
Reason for Medicare Entitlement: Age
(First)
Medicare Number (please include
alpha prefix):
Disability
ERSD
E n r o l l i n g I n d i v i d u a l N a m e (Last)
Medicare
Part A
Part B
Part D
Effective Date:
/_
/_
Reason for Medicare Entitlement: Age
GR-67834-49 (1-11)
(MI)
Dual Enrollment
(First)
(MI)
Medicare Number (please include
alpha prefix):
Disability
ERSD
5
Dual Enrollment
(V1)
Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
F
Employee Name
Health Statement
Instructions:
1.
The information you provide in this application is confidential. You should discuss with your employer if
you prefer to submit the completed health statement directly to the insurance company or insurance
broker.
2.
The health information you provide below will be used by the insurance company to determine the
price to charge your group for the coverage applied for and whether a Pre-Existing Condition Waiting
Period(s) will apply to your coverage. Coverage for pre-existing conditions cannot be limited or
excluded for dependents under the age of 19.
3.
Each medical question below applies to all persons requesting coverage.
4.
Answer the questions below with either Yes or No. If you answer Yes to any question, you must
provide additional information in Section G below.
5.
Do not leave any question unmarked.
6.
Neither your employer nor your insurance agent can waive these requirements or may authorize you to
provide anything less than a complete and accurate response to each of the questions.
7.
After you submit this application, the insurance company may call you to obtain additional confidential
information needed to evaluate and aid the processing of your application.
1 For the following conditions, w i t h i n t h e p a s t 5 y e a r s , have you or any dependents for whom
you are requesting 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 related to any of the categories listed below?
A. Cardiovascular disease or heart attack, stroke, high blood pressure, or any
Yes
No
B. Cancer or cancerous tumor?
Yes
No
C. Asthma, emphysema, tuberculosis, or any other disorder of the lungs or
Yes
No
Yes
No
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
other disease or disorder of the heart, arteries, blood, or blood vessels?
respiratory system?
D. Diabetes? If yes, check all that apply:
□ Non-Insulin Dependent □ Insulin Dependent □ Insulin Pump
GR-67834-49 (1-11)
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(V1)
Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
Employee Name
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
Yes
No
If yes, are multiples (twins, triplets, etc.) expected?
Yes
No
Are there any known complications, or is a cesarean section planned?
Yes
No
Employee:
Yes
No
Spouse/Domestic Partner:
Yes
No
Yes
No
Yes
No
2 Are you, your spouse/domestic partner, or any dependent for whom you are requesting
coverage currently pregnant?
Due Date:
/_
/_
(MM/DD/YYYY)
3 W i t h i n t h e p a s t 1 2 m o n t h s , have you or your spouse/domestic partner
used any tobacco products?
4 W i t h i n t h e p a s t 1 2 m o n t h s , has any applicant been prescribed medication
(other than for the common cold or flu) that is n o t i n d i c a t e d e l s e w h e r e i n
this application?
5 W i t h i n t h e p a s t 5 y e a r s , 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 a n y i l l n e s s , i n j u r y o r
health condition not indicated above?
G
Additional Information
I f y o u a n s w e r e d “ Y e s ” t o any o f t h e q u e s t i o n s a b o v e , y o u m u s t c o m p l e t e t h i s s e c t i o n .
If additional space is required, please attach a separate sheet and be sure to sign and date that sheet.
Question Number:
Name of Individual:
Condition/Diagnosis:
Treatment Received:
Treatment ongoing?
Date Diagnosed (MM/YYYY):
Yes
No
Last Treatment Date:
Surgery, additional tests or treatment recommended?
Medication Prescribed (if any):
Currently taking medication?
Question Number:
No
Yes
No
Name of Individual:
Condition/Diagnosis:
Treatment Received:
Treatment ongoing?
Yes
Date Diagnosed (MM/YYYY):
Yes
No
Last Treatment Date:
Surgery, additional tests or treatment recommended?
Medication Prescribed (if any):
Currently taking medication?
GR-67834-49 (1-11)
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(V1)
Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
Employee Name
Question Number:
Name of Individual:
Condition/Diagnosis:
Treatment Received:
Treatment ongoing?
Date Diagnosed (MM/YYYY):
Yes
No
Last Treatment Date:
Surgery, additional tests or treatment recommended?
Medication Prescribed (if any):
Currently taking medication?
Question Number:
No
Yes
No
Yes
No
Yes
No
Yes
No
Name of Individual:
Condition/Diagnosis:
Treatment Received:
Treatment ongoing?
Yes
Date Diagnosed (MM/YYYY):
Yes
No
Last Treatment Date:
Surgery, additional tests or treatment recommended?
Medication Prescribed (if any):
Currently taking medication?
Question Number:
Name of Individual:
Condition/Diagnosis:
Treatment Received:
Date Diagnosed (MM/YYYY):
Treatment ongoing?
Yes
No
Last Treatment Date:
Surgery, additional tests or treatment recommended?
Medication Prescribed (if any):
Currently taking medication?
Question Number:
Name of Individual:
Condition/Diagnosis:
Treatment Received:
Treatment ongoing?
Date Diagnosed (MM/YYYY):
Yes
No
Last Treatment Date:
Surgery, additional tests or treatment recommended?
Medication Prescribed (if any):
Currently taking medication?
Question Number:
Name of Individual:
Condition/Diagnosis:
Treatment Received:
Treatment ongoing?
Date Diagnosed (MM/YYYY):
Yes
No
Last Treatment Date:
Surgery, additional tests or treatment recommended?
Medication Prescribed (if any):
Currently taking medication?
GR-67834-49 (1-11)
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Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
H
Employee Name
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 # (if applicable):
Vision
Basic Life
Short - T erm Disability
Dependent Life
Voluntary Life:
Amount (if applicable): $
Long - T erm Disability
Employee Class (employer will provide you with this information if needed):
Salary (if requesting life or disability coverage): $
Hourly
Weekly
Monthly
Semi-monthly
Annually
Spouse/Domestic Partner
Dental:
PPO
HMO
Dental HMO Office ID # (if applicable):
Vision
Basic Life
Short - T erm Disability
Dependent Life
Voluntary Life:
Amount (if applicable): $
Long - T erm Disability
Child(ren)
Dental:
PPO
HMO
Dental HMO Office ID # (if applicable):
Vision
Basic Life
Short - T erm Disability
Dependent Life
Voluntar y Life:
Amount (if applicable): $
Long - T erm Disability
B e n e f i c i a r y I n f o r m a t i o n (if requesting life insurance)
Primary Beneficiary Name (Last, First, MI)
Relationship
Benefit %
Secondary Beneficiary Name (Last, First, MI)
Relationship
GR-67834-49 (1-11)
Benefit %
9
(V1)
Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
ILLINOIS STANDARD HEALTH APPLICATION – SMALL EMPLOYER
Employer Name
Employee Name
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, in which case any claim I submit may not be paid by the
insurer. I understand that if I intentionally omit or provide false information on or in relation to this
application that I may face legal liability, including legal action based on fraud.
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, for which I am presently eligible or
for which I may become eligible under my employer’s group contract(s). If any deductions are required for this coverage,
I authorize such deductions from my earnings. I reserve the right to revoke this deduction authorization at any time upon
written notice.
I understand that the information I have provided in this application will be used by the insurance carrier and its affiliates
to make decisions regarding eligibility, enrollment, underwriting, and premium risk rating.
I understand that the medical information provided also includes my spouse/domestic partner and/or dependents’
information.
I understand that I may be asked for authorization to disclose my medical, claim, or benefit records at a later time.
I understand that I should retain a duplicate copy of this application for my own records.
A photographic copy of this acknowledgment shall be as valid as the original.
I authorize the insurance carrier to electronically transmit the information contained herein.
If this application was taken over the phone or on the computer, I acknowledge that I, myself, have not actually signed
this application but instead hereby authorize the insurance carrier to print “Electronically Acknowledged” on the
signature line of the application and I agree that such printing shall be treated as a valid signature for all purposes of this
form. I acknowledge that the insurance carrier has verified my identity for this purpose in accordance with any applicable
law or regulation.
By signing below, I acknowledge that I have read and understand this document and I am signing of my own free will.
Employee Signature
Date
✪ 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.
GR-67834-49 (1-11)
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(V1)
Aetna Life Insurance Company NAIC No.: 001-60054
Aetna Health Inc. NAIC No.: 95109
