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Important Plan Coverage Information: All UnitedHealthcare plans are underwritten by UnitedHealthcare Insurance Company. When adding or
revising plans at renewal, underwriting approval may be required. All plan change requests must be submitted to UnitedHealthcare prior to the
renewal date.
1
Groups with 5 or more enrolling employees may offer one staff model HMO plan from another carrier alongside UnitedHealthcare plans.
2
UnitedHealthcare Navigate®.
Formal product name: UnitedHealthcare Multi-Choice®.
Formal HMO product names:
Signature = UnitedHealthcare SignatureValue®
Advantage = UnitedHealthcare SignatureValue Advantage
Alliance = UnitedHealthcare SignatureValue Alliance
Focus = UnitedHealthcare SignatureValue Focus
Harmony = UnitedHealthcare SignatureValue Harmony
The Navigate network included herein is subject to approval by regulators. If the Navigate network offered herein is subsequently modified by
regulators, we will immediately advise you of the change in network, in accordance with applicable law.
Premium rates and/or product forms included herein are subject to approval by regulators. If the rates or product forms offered herein are
subsequently modified by regulators, we will immediately advise you of the change in plan design and retroactively adjust premium in subsequent
billings, in accordance with applicable law.
Health plan coverage provided by or through UnitedHealthcare Insurance Company, UHC of California and UnitedHealthcare Benefits Plan of
California. Administrative services provided by United Healthcare Services, Inc., OptumRx or OptumHealth Care Solutions, Inc. Behavioral health
products are provided by U.S. Behavioral Health Plan, California (USBHPC).
UnitedHealthcare Life and Disability products are provided by Unimerica Life Insurance Company in California.
B2B EI20225926.0 8/20 © 2020 United HealthCare Services, Inc. 20-188641 400-6982 UHCCA756308-008
Facebook.com/UnitedHealthcare
Twitter.com/UHC
Instagram.com/UnitedHealthcare
YouTube.com/UnitedHealthcare
Please Indicate Dental and Vision Plan Selection
(Select up to a maximum of two HMO and PPO dental plans. Select up to a maximum of one vision plan.)
Dual Option
Other _____________________________________
UnitedHealthcare DPPO
Dental Plan Code ___________________________
UnitedHealthcare DHMO
Dental Plan Code ________________________________
Pacific Dental Benefits Direct Compensation DHMO
Direct Compensation Plan Code ___________________
UnitedHealthcare Vision
Vision Plan Code _______________________
Please Indicate Financial Protection Plan Selection
Supplemental Benefits
Employee Basic Life and AD&D
Dependent Life and AD&D
Supplemental Employee Life and AD&D
Supplemental Dependent Life and AD&D
Long-Term Disability
Protection Plans available for groups with 51 or more eligible employees:
Critical Illness Protection
Accident Protection
Hospital Indemnity Protection
Infertility (HMO only)
Diagnosis and Treatment
Infertility (Core State Plans only)
Diagnosis and Treatment
HSA Supplemental Coverage
HSA (if selected) – Bank to be used: Optum Bank® Other
The undersigned is authorized by the above Small Business Group to apply for or change group coverage offered
by UnitedHealthcare Insurance Company at the attached premium rates guaranteed for 12 months effective
_____________________ and is authorized to enter into a Medical and Hospital Group Master Policy.
Further, the undersigned agrees to make full monthly premium payments to UnitedHealthcare for the benefits received in
accordance with the terms of the contract.
Authorized Signature Date
Print Name Title
California law prohibits an HIV test from being required or used by health CARE
SERVICE PLANS and insurance companies as a condition of obtaining coverage.
UNDERWRITING APPROVAL
D. P. Only
INTERNAL USE ONLY: G.C. #
Group Name
