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Utah Health Insurance Application Form

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Utah Small Employer Health Insurance Application

January 2014

OFFICE USE ONLY

Policy / Group No.

Effective Date

New Hire Waiting Period

REASON FOR ENROLLMENT (mark all that apply)

New Group Newborn Loss of Coverage

Open Enrollment Court Order Marriage

New Hire Dependent Addition Divorce

New Application Other: Military Leave of Absence (USERRA)

COBRA Utah mini-COBRA

Length of continuation coverage: 12 mos. 18 mos. 36 mos. Other:

Original Qualifying Event Date: Qualifying Event Date: Date of Event:

WAIVER OF COVERAGE Individuals waiving coverage complete Waiver of Coverage.

A. EMPLOYER INFORMATION

Employer Is this a division? Yes No If “Yes,” name of parent company

B. EMPLOYEE INFORMATION

Name (Last) (First) (MI) Job Title Hrs/Week

Employment status Full-time Owner/business partner Retired Other Hire Date Rehire Date

Marital Status Legally Married Single Divorced Widowed Domestic Partner

Home Address Apt. City State Zip

Mailing Address Apt. City State Zip

Home/Cell Phone Business Phone Email Address

If you are American Indian or Alaska Native, provide the state and name of your federally-recognized tribe:

C. ENROLLING EMPLOYEE / SPOUSE / DOMESTIC PARTNER* / DEPENDENTS

List yourself and all dependents applying for coverage. Attach a separate sheet if necessary.

Relationship Name (Last, First, Middle) Social Security # Date of Birth Gender Tobacco Use
Employee Male Female Yes No
Spouse/Domestic Partner Male Female Yes No
Dependent Male Female Yes No
Dependent Male Female Yes No

*Check with your employer to determine if domestic partner coverage is available.

D. CURRENT COVERAGE INFORMATION

Please indicate for EACH person listed on this application any health care coverage, Medicaid, or Medicare currently in effect. This will be used to determine if benefits will be coordinated. Each person applying for coverage must be listed below. If no health care coverage is in effect, indicate NONE. If coverage is provided for a dependent from a previous marriage or relationship, please attach a copy of the court documentation that shows who is responsible for the dependents’ health care coverage so that the insurer can determine whose coverage is primary. Attach a separate sheet if necessary.

Name of Individual Insurer Date of Coverage
MM/YY		 Will coverage continue? Type of Coverage
Employee Yes No Employer group Individual Medicare Governmental Other
Spouse/Domestic Partner Yes No Employer group Individual Medicare Governmental Other
Dependent Yes No Employer group Individual Medicare Governmental Other
Dependent Yes No Employer group Individual Medicare Governmental Other
Dependent Yes No Employer group Individual Medicare Governmental Other

E. ACKNOWLEDGMENT AND SIGNATURE

I agree to abide by the insurer’s enrollment provisions. I understand that coverage cannot start until after the waiting period. I authorize my employer to act as my agent in all matters of administration of the group program.

I acknowledge that I have had the opportunity to waive coverage for myself and any eligible dependents.

If the policy contains a voluntary arbitration provision: ANY MATTER IN DISPUTE BETWEEN YOU AND THE INSURER MAY BE SUBJECT TO ARBITRATION AS AN ALTERNATIVE TO COURT ACTION PURSUANT TO THE RULES OF THE AMERICAN ARBITRATION ASSOCIATION OR OTHER RECOGNIZED ARBITRATOR, A COPY OF WHICH IS AVAILABLE ON REQUEST FROM THE INSURER. THE INSURER SHALL BEAR THE COSTS OF ARBITRATION, FILING FEES, ADMINISTRATIVE FEES AND ARBITRATOR FEES. OTHER EXPENSES OF ARBITRATION, INCLUDING, BUT NOT LIMITED TO: ATTORNEY FEES, EXPENSES OF DISCOVERY, WITNESSES, STENOGRAPHER, TRANSLATORS, AND SIMILAR EXPENSES, WILL BE BORNE BY THE PARTY INCURRING THOSE EXPENSES. ANY DECISION REACHED BY ARBITRATION SHALL BE BINDING UPON BOTH YOU AND THE COMPANY. THE ARBITRATION AWARD MAY INCLUDE ATTORNEY'S FEES, IF ALLOWED BY STATE LAW, AND MAY BE ENTERED AS A JUDGMENT IN ANY COURT OF PROPER JURISDICTION.

I certify that all information completed on this form is true, correct and complete. I acknowledge that if any information provided is false, the insurer may without advance notice pursue any remedies available under state or federal law, including declaring the coverage null and void and canceling the coverage retroactive to its original effective date.

I have read the Acknowledgment of this document and agree to its terms.

Employer:

Employee Name (Last) (First) (MI)

Employee Signature Date

WAIVER OF COVERAGE

COMPLETE WHEN WAIVING COVERAGE FOR SELF AND/OR DEPENDENTS

Employee Name (Last) (First) (MI)

Employer:

INDIVIDUALS WAIVING COVERAGE

Name of individual waiving coverage Reason for waiving coverage Insurer (Including policyholder name, insurer name and phone number) Will coverage continue?
Employee Other employer group coverage
Individual coverage
Governmental (Medicare, Medicaid, Tricare, etc.)
Other 		Yes
No
Spouse / Domestic Partner Yes
No
Dependent Yes
No
Dependent Yes
No
Dependent Yes
No

ACKNOWLEDGEMENT AND SIGNATURE

I acknowledge that I have had the opportunity to enroll, but do not wish to make application for those individual(s) listed above. In waiving coverage, I am aware that waiving individuals (including myself, if I am waiving) may not enroll until my group’s anniversary, unless the waiving individual qualifies for a Special Enrollment Period (SEP). If I have waived enrollment for myself or any of my dependents (including my spouse/domestic partner) because of other health care coverage or group health plan coverage, I may in the future be qualified for a SEP and be able to enroll the waived individuals in this plan, provided I request enrollment within 30 days after the other coverage of the individual(s) ends due to loss of eligibility or an employer’s ceasing to contribute toward that other coverage (within 60 days if the other coverage was Medicaid or CHIP). In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I further certify that all information completed on this Waiver of Coverage form is true, correct and complete.

Employee Signature Date

Non-Discrimination Notice

SelectHealth complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

We provide free aid and services to people with disabilities to help them communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). We also provide free language services to people whose primary language is not English, such as qualified interpreters and member materials written in other languages.

If you need these services, please call SelectHealth Member Services at 1-800-538-5038. Any member or other person who believes he/she may have been subject to discrimination may file a complaint or grievance by calling the SelectHealth 504/Civil Rights Coordinator at 1-844-208-9012 or the Compliance Hotline at 1-800-442-4845 (TTY Users: 711). You may also call the Office for Civil Rights at 1-800-368-1019 (TTY Users: 1-800-537-7697).

Language Access Services

Spanish: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame a SelectHealth: 1-800-538-5038.

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 SelectHealth: 1-800-538-5038。

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số SelectHealth: 1-800-538-5038.

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. SelectHealth: 1-800-538-5038. 번으로 전화해 주십시오.

Navajo: Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dęʹęʹ’, t’áá jiik’eh, éí ná hólǫʹ, kojį’ hódíílnih SelectHealth: 1-800-538-5038.

Nepali: ध्यान दिनुहोस्: तपार्इंलेनेपाली बोल्नुहुन्छ भने तपार्इंको निम्ति भाषा सहायता सेवाहरूनिःशुल्क रूपमा उपलब्ध छ । SelectHealth: 1-800-538-5038 मा फोन गर्नुहोस्।

Tongan: FAKATOKANGA’I: Kapau ‘oku ke lea fakatonga, ko e kau fakatonu lea te nau tokoni atu ta’etotongi, pea te ke lava ‘o ma’u ia. Telefoni ki he SelectHealth: 1-800-538-5038.

Serb-Croatian: ОБАВЕШТЕЊЕ: Ако говорите српски језик, услуге језичке помоћи доступне су вам бесплатно. Позовите SelectHealth: 1-800-538-5038.

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa SelectHealth: 1-800-538-5038.

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: SelectHealth: 1-800-538-5038.

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги переводчика. Позвоните SelectHealth: 1-800-538-5038.

Arabic: ةدعاسملا تامدخ نإف ،ةيبرعلا ثدحتت تنك اذإ :ةظوحلم ةكرشب لصتا .ناجملاب كل رفاوتت ةيوغللا SelectHealth: 1-800-538-5038.

Mon-khmer, Cambodian: សម្គាល់៖ បើសិនជាអ្នកនិយាយ ភាសាខ្មែរ សេវាជំនួយផ្នែកភាសា ដោយមិនគិតថ្លៃ គឺអាចមានសំរាប់ អ្នក។ សូមទូរស័ព្ទមក SelectHealth: 1-800-538-5038 ។

French: ATTENTION : si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Contactez SelectHealth: 1-800-538-5038.

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。SelectHealth: 1-800-538-5038. まで、お電話にてご連絡ください。

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What the Utah Health Insurance Application Form Is

The Utah Health Insurance Application Form is a standardized document used by insurance applicants to provide personal, demographic, medical, and financial information required to enroll in state-regulated health plans or private policies sold in Utah. It collects identity details, coverage preferences, prior coverage history, and any disclosures necessary for underwriting and eligibility determination. Insurers and brokers use the form to evaluate risk, calculate premiums, and process enrollment. Completing the form accurately supports timely processing and ensures applicants receive correct policy terms, premium calculations, and legal notices required under state and federal law.

Why this Form Matters for Enrollment and Compliance

The Utah Health Insurance Application Form centralizes applicant data for underwriting, enrollment, and compliance. It reduces back-and-forth information requests, documents consumer consent for electronic communications, and creates a consistent record used for eligibility decisions and downstream claims processing under applicable state and federal regulations.

Why this Form Matters for Enrollment and Compliance

Who Completes or Relies on the Form

Typical users include applicants, insurance agents, employers, and plan administrators who manage enrollment and benefits administration in Utah.

  • Individual applicants submitting primary or dependent coverage enrollment and eligibility information.
  • Insurance agents and brokers completing applications on behalf of clients during sales meetings.
  • Employers and benefits administrators enrolling employees in group health plans and reporting changes.

Each party must ensure disclosures, signatures, and supporting documents are complete to avoid processing delays or coverage denials.

Essential Sections to Include on a Professional Application

Core sections of a professional Utah Health Insurance Application Form organize applicant identity, coverage choice, medical history, prior coverage, authorization, and disclosures for clear underwriting and enrollment.

Applicant Info

Collect full legal name, date of birth, gender, Social Security number or TIN, residential address, and contact details to verify identity and match to existing records during underwriting and eligibility checks.

Coverage Selection

Specify plan type, coverage tier, requested effective date, dependent listings, and any optional riders to ensure accurate premium calculations and that benefits align with applicant selections and employer-sponsored plan parameters.

Medical History

Disclose pre-existing conditions, current medications, recent treatments, and tobacco use; provide accurate dates and provider names to support underwriting determinations and avoid material misrepresentation issues.

Prior Coverage

List previous health plans, lapse dates, COBRA coverage, and reasons for termination to determine waiting periods, coordination of benefits, and any pre-existing condition exclusions under applicable policy rules.

Authorizations

Include HIPAA-compliant authorization for release of medical records, consent to electronic transactions per ESIGN, and applicant attestation that statements are true under penalty of perjury where required.

Signatures

Provide signature blocks for the applicant, any spouse or dependent over signature threshold, and the enrolling agent with dates; include witness or notary fields if state law or insurer requires.

Step-by-Step: Completing the Form

Follow these steps to complete the Utah Health Insurance Application Form accurately and reduce processing time.

  • 01
    Gather Documents: ID, SSN/TIN, prior policy numbers
  • 02
    Fill Sections: Enter personal, medical, and coverage details
  • 03
    Attach Proof: Upload ID and previous coverage proof
  • 04
    Sign & Submit: Sign using wet or compliant e-signature

Recommended Online Workflow Settings

Configure an online workflow to collect, validate, and route Utah Health Insurance Application Forms automatically.

Field Configuration
Validation Rules Require MM/DD/YYYY for dates; SSN format check
Conditional Fields Show medical questions if prior coverage yes
Authentication Email link with optional SMS code or KBA
Notifications Notify agent and applicant on submission

How Electronic Submission and Processing Works

This workflow explains document routing and processing from initial applicant submission through underwriting, carrier enrollment, and final confirmation to the applicant and agent.

  • Submit: Applicant completes and submits application online
  • Verify: System verifies identity and required fields
  • Underwrite: Carrier reviews disclosures and medical data
  • Enroll: Policy issued and confirmation sent

Technical Requirements for Online Deployment

Support for common file types, integrations, and eSignature methods reduces friction when deploying online application workflows in organizations of any size.

  • File Types: PDF, DOCX, HTML supported
  • Integrations: Salesforce, NetSuite, Microsoft 365 integrations
  • Authentication: Email, SMS, SSO, optional KBA

Timing and Reporting Deadlines to Keep in Mind

Key filing and timing expectations for processing Utah health insurance submissions and related tax reporting.

Application Effective Date:

Use MM/DD/YYYY; insurer may set waiting periods

Agent Submission Window:

Submit within insurer's enrollment period or employer open enrollment

1095 Reporting:

Employers must provide 1095 forms by Jan 31 where applicable

Tax Forms Timing:

W-2 and 1099 deadlines typically Jan 31

Appeals Period:

Follow insurer grievance timelines per policy and state rules

Common Preparation Pitfalls to Avoid

  • Leaving fields blank for prior coverage dates leads to coordination of benefits errors and possible premium recalculation or denial.
  • Using nicknames or initials instead of full legal names causes identity mismatches and may require notarized affidavits to correct.
  • Failing to sign authorizations for medical records or electronic consent invalidates HIPAA authorizations and stalls underwriting.
  • Uploading low-quality ID scans or mismatched addresses increases verification failures and can trigger requests for certified documents.

Consequences of Inaccurate or Incomplete Submissions

Coverage Denial: Material misstatements can void coverage
Premium Errors: Incorrect data causes wrong premiums
Tax Withholding: Missing TIN triggers 24% backup withholding
Filing Penalties: Late/incorrect 1099 triggers IRC §6721 fines
Privacy Fines: HIPAA violations risk civil and criminal penalties
Processing Delays: Incomplete forms delay enrollment and claims

Security and Compliance Features to Look For

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
HIPAA: Compliant; BAA available upon request
Certifications: ISO 27001, SOC 2 Type II, PCI DSS
Regulatory: ESIGN and UETA compliant
Accessibility: WCAG 2.0 Level AA support
Auditing: Detailed audit trail and timestamps

Vendor Pricing and Feature Snapshot for eSignature Solutions

Comparison of common eSignature vendors and features relevant to processing Utah Health Insurance Application Forms.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by vendor Varies by vendor Varies by vendor Varies by vendor
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently Asked Questions About the Application

Answers to common questions about completing, signing, and submitting the Utah Health Insurance Application Form, including digital signature and privacy concerns.


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