Statement of Understanding
By signing this application, I represent that all my answers are complete and
accurate, and that I understand and agree to the following conditions:
• I agree to abide by all of the terms and conditions of the group policy.
• No independent producer, agent or employee of the insurer, or my
employer can change any part of this application or waive the requirement
that I answer all questions completely and accurately.
• The insurer may, at its discretion, request supplemental information
from me, any family member listed on this application or any health care
provider.
• On behalf of myself and all enrolled family members, I understand if
the insurer discovers any intentional misrepresentation, omission or
concealment of fact in obtaining coverage that was or would have been
material to the insurer’s acceptance of a risk, extension of coverage,
provision of benefits or payment of any claim, the insurer may take action
against my employer, including but not limited to increasing premiums.
• If this application is approved, coverage for myself and any eligible family
members named on this application will begin on the date assigned by the
insurer.
• I acknowledge and understand my health plan may request or disclose
health information about me or my dependents (persons who are listed
for benefits coverage on the enrollment form) from time to time for the
purpose of facilitating health care treatment, payment or for the purpose
of business operations necessary to administer health care benefits; or as
required by law. For more information about such uses and disclosures,
including uses and disclosures required by law, please refer to the
Blue Cross of Idaho Notice of Privacy Practices that is available at
bcidaho.com.
• My employer’s master group policy is the document that sets forth all
terms of my coverage, and no independent producer, agent or other
person can change the terms of the master group policy, any of its
amendments, or this application, except with an amendment issued
expressly for that purpose and signed by an authorized officer of the
insurer.
• I agree that a facsimile or photocopy of my signature will serve the
same as an original.
• I understand that this application will become part of the contract between
the insurer and my employer.
• I affirm that I have reviewed all answers given on this application and,
regardless of whether an independent producer or other person has filled
out the answers for me, I verify that the answers are true and complete.
• I have read and understand the group health plan dependent eligibility
requirements and further understand that I am required at the time a
dependent loses eligibility to submit an application removing the ineligible
dependent from coverage within thirty (30) days. I further understand and
agree that failure to do so may result in recovery of benefits to the extent
allowable by law.
APPLICATION MUST BE SIGNED AND DATED
Signature_______________________________________________
Date_____________________________
Current/Prior Coverage Information (Please complete for proper coordination of benefits administration.)
Is any person listed on this application now covered by any other health insurance, including Medicare, Medicaid, or other Blue Cross of Idaho policy?
❏ Yes ❏ No If YES, please complete all information
below for each person listed on this application.
Applicant’s Name Name of Carrier Policy Number
Type of Policy
(Group or Individual)
Start Date of
Policy
(mm/dd/yy)
Will Current
Policy
Continue?
*
Employee
❏ Ye s ❏ No
Spouse
❏ Ye s ❏ No
Child
❏ Ye s ❏ No
Child
❏ Ye s ❏ No
Child
❏ Ye s ❏ No
If any person listed on this application is covered by Medicare, please complete the following:
_______________________________________________________________ ________________________________________ ___________________________________________________
Name Medicare Beneficiary Number Reason for Medicare Entitlement (age, disability of ESRD)
Date of Medicare Entitlement: Part A ________________________________ Part B _________________________________
mm dd yy mm dd yy
*
If your current coverage will remain active, please indicate if coverage is for: q Medical q Dental q Vision
*
If your current coverage will be terminated, please indicate termination date:
mm dd yy
Disability Information
Total disability is a condition resulting from disease or accidental injury, as certified in writing by an attending physician, that renders the enrollee/
member incapable of performing the principal duties of regular employment/occupation for which he/she is qualified/trained and he/she is not
engaged in any work, profession or avocation for fees, gain or profit; or he/she is unable to engage in the normal activities of an individual of the
same age and gender.
Are you or any of your dependents currently totally disabled? ❏ YES ❏ NO (If YES, complete information below.)
______________________________________________________________________________________________________________________________________________
Nature of Total Disability
________________________________________________________ ___________________________________________________________________________________
Name of Totally Disabled Person Physician’s Name Physician’s Phone Number
________________________________________________________ ___________________________________________________________________________________
Date of Total Disability Physician’s Address
Form No. 3-700 (09-15)
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signature
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