Have you or any member of your family been enrolled in other medical or dental coverage?
If yes, what type of coverage? ☐Medical ☐Dental
//☐Dental: __//What is the effective date of the other coverage? ☐Medical: ____ ____ ______ __ ____ ______
What is the name of the other carrier? _______________________________
Are you keeping the coverage? ☐Yes ☐No
//☐Dental: __//If no, when will the coverage end? ☐Medical: ____ ____ ______ __ ____ ______
ID#(s) _Policyholder’s name _________________________________ ________________________________________
Who did the insurance cover? ☐Self Only ☐Self & Spouse/Domestic Partner ☐Self & Child(ren) ☐Family
I acknowledge and agree that by signing this enrollment form and subsequently accepting services, I and everyone else
who is covered under the contract you issue is bound by the terms and conditions of the contract applicable to my
coverage. This includes, without limitation, the terms and conditions regarding the receipt and release of medical records
and information. I make this acknowledgment and agreement on behalf of myself and each other person who accepts
coverage under the terms of the contract applicable to my coverage (who may include, for example my spouse and my
eligible family dependents).
I hereby accept responsibility for payment of any portion of the premium.
I hereby represent that all information furnished by me hereon is true and complete to the best of my knowledge.
Pediatric dental is an essential health benefit mandated by the ACA. If your employer group does not provide pediatric
dental coverage through this Univera Healthcare plan, you agree to enroll in the dental plan offered to you by your
PREFERRED PROVIDER ORGANIZATION (PPO)
I understand that the Preferred Provider Organization (PPO) coverage is comprised of an in-network benefit that is
dependent on the utilization of medical providers who participate with the PPO and out-of-network benefit that provides
coverage for services of medical providers who do not participate with the PPO. I understand that the in-network benefit
provides the highest level of coverage under the plan.
I have thoroughly read, understand and agree to comply with the terms of the release in this section.
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the
stated value of the claim for each such violation.
Subscriber Signature ____________________________________________________ _____________________
☐Dependent Child ☐Disabled Dependent Child (Separate application form required) ☐Other___________________
_____ __________________________________________ ___________ ________________________________
Last Name (if different) Title First Name MI Social Security Number **
Gender assigned at birth:
☐Male ☐Female Birthdate ______ ______ ________
Transgender Male ☐Gender identity
☐ _______Transgender Female ☐Non-binary ☐Prefer not to say ☐Prefer to self-describe:
//Is dependent a full-time student over age 19? ☐Yes ☐No Married? ☐Yes ☐No Expected Graduation Date: _____ _____ ________
Will dependent further education after graduation? ☐Yes ☐No If yes, please provide name of college/university _______________________________
Medicare Eligible ☐Yes ☐No If yes, indicate reason ☐Age 65+ ☐Disability ☐End Stage Renal *
Part B Effective Date: ___ /___ //___ /Part A Effective Date: __________________________ ___ ____ ____
Medicare Number (if applicable)
Please return to P.O. Box 211256 Eagan, MN 55121-2656
If you have questions, please contact your Group Administrator. Or, visit us at: UniveraHealthcare.com
Note: Use an additional application [or addendum] if more than three dependents need coverage.
Section 6: Other coverage information (Required) - You may be contacted for additional information
Section 7: Release - You must sign and date this form to be eligible for health insurance
Subscriber’s Last Name: _____________________________
APP-352 (0719) U Mid/Large Group