Commercial Group Health Insurance Application/Change Form
Please print clearly and complete all sections that apply. Signatures are required. Additional instructions included on Page 4.
Page 1
HIOS ID# ___________________
EC _________________________
FOR INTERNAL USE ONLY
Section 1: Employer Group & Benefit Information - To be completed with your Group Administrator
Medical Plan Selection
APP-352 (0719) U Mid/Large Group
Section 2: Subscriber’s Information
_________________________________
Last Name
_____________________________
First Name
_________ ___________
Middle Initial Title
(e.g., Jr, Sr, III, etc.)
________________________________________________
Street Address
____________________________________ ________
City State
_______________________ _____________________
Zip Code Phone
Birthdate: _______ /_______ /____________
Gender assigned
at birth:
Male
Female
Social Security Number** __________________________
Date of Hire/Rehire: _______ /_______ /___________
Retirement Date: _____ /_____ /________
______________________________________________________________________________
Employer Name Association/Chamber Name (if applicable)
____________________________________________________ ________________ ___________________
Group Administrator’s Signature (required) Date Employee Number Department Number
_____________________________
Subscriber’s Medica
re Number (if applicable)
_____ /_____ /_______ _____ /_____ /_______
Medicare Part A Effective Date Medicare Part B Effective Date
Medical Information
________________________
Medical Group Number (8 digits)
________________________
Medical Subgr
oup Number (4 digits)
________________________
Medical Class N
umber (e.g. A001)
If enrolling in a Medical
plan, who do you need
coverage for?
Self Only
Self & Child(ren)
Self & Spouse, or
Self & Domestic Partner
Family
_____ /______ /______
Medical Effective Date
Dental Information
_________________
Dental Group Number
_________________
Dental Subgroup Number
_________________
Dental Class
If enrolling in a Dental
plan, who do you need
coverage for?
Self Only
Self & Child(ren)
Self & Spouse, or
Self & Domestic Partner
Family
____ /_____ /_____
Dental Effective Date]
Dental Plan Selectio
n
Age 65+
Disability
End Stage Renal *
Subscriber
Status:
Actively
Working
Retired
Disabled
Canceled
COBRA
Check Desired Action
Add Cancel Change
Gender identity (optional):
Transgender Male
Transgender Female
Prefer to self-describe: _____________
Prefer not to say
Non-binary
Daemen College
00130563
N/A
N/A
N/A
Univ PPO Signature Copay 1 (DAA)
Univ PPO Signature Deductible 3 (DAG)
Not Applicable (N/A)
Cancel Codes:
SB02-Left Employment SB05-Per Group Request SB06-Subscriber Request
(voluntary)
SB07-Deceased SB09-Enrolled in Error
Cancel Codes:
M001-Per Group Request M004-Enrolled in Error M008-Moved Out of Area M013-Ineligible
M002-Deceased M005-Divorced M010-Overage Dependent M014-YAO Ineligible
M003-Per Subscriber Request M007-Per Member Request (voluntary) M011-No Longer a Student M040-Mx Same Group
Spouse Domestic Partner 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 ______ /______ /_________
Married? Yes No
Gender identity (optional): Transgender Male Transgender Female Non-binary Prefer not to say Prefer to self-describe: _________
Is depend
ent a full-ti
me student over age 19? Yes No Expected Graduation Date: _____ /_____ /________
If yes
, please provide name of college/university _______________________________ Will dependent further education after graduation? Yes No
Medicare Eligible Yes No If yes, indicate reason Age 65+ Disability End Stage Renal *
__________________________ Part
A Effective Date: ___ /___ /____ Part B Effective Date: ___ /___ /____
Medicare Number (if applicable)
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 ______ /______ /_________
Married? Yes No
Gender identity (optional): Transgender M
ale Transgender Female Non-binary Prefer not to say Prefer to self-describe: __________
Is dependent a full-time s
tudent over age 19? Yes No Expected Graduation Date: _____ /_____ /________
If yes,
please provide name of college/university _______________________________ Will dependent further education after graduation? Yes No
Medicare Eligible Yes No If yes, indicate reason Age 65+ Disability End Stage Renal *
__________________________ Part A Effective Date: ___ /___ /____ Part B Effective Date: ___ /___ /____
Medicare Number (if applicable)
Enrollment Opportunity
:
New Hire
Rehire
Open Enrollment
Medicare eligible
Special Enrollment Opportunity: Newly Eligible Dependent: Newborn Marriage Other _______________
Change in employment status A move in o
r out of the service area
Involuntary loss of coverage Former dependent regains eligibility
COBRA Election - Please indicate the reason for COBRA if applicable:
Left Employment/Retired Divorce/Legal Separation Loss of Student Status Death of Spouse
Disability Dependent Reached Max Age Other: ______________________________________
Demographic Change:
Address
Birthdate
Subscriber Name
Dependent Name
Phone Number
Subscriber
Cancel Code:
Medical Cancel Date:
Dental Cancel Date:
/ /
/ /
Dependent(s)
Dependent Name:
Cancel Code:
Medical Cancel Date:
Dental Cancel Date:
/ / / /
/ / / /
/ / / /
Additional Dependent(s)
Date of Event ___ /___ /______
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Section 4: Cancel Information - If canceling coverage, who are you canceling coverage for?
Section 3: Reason for enrollment or change - To be completed by the Group Administrator - Not required for cancelations
Subscriber’s Last Name: _____________________________
Section 5: Information about who you would like coverage for (dependent information)
A
PP-352 (0719) U Mid/Large Group
Have you or any member of your family been enrolled in other medical or dental coverage?
Yes
No
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
Date
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
employer.
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
(optional):
_______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
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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
Instructions for completing the Group Health Insurance Application/Change Form
Section 1: Employer Group & Benefit Information
This section should be completed with your Group Administrator. Group Administrator’s signature is required. Medical
and/or dental group numbers and information must be populated. Select who you need coverage for on the medical
and/or dental plan(s) and indicate the subscriber’s status. Next, select the medical and/or dental plan(s) you are enrolling
in. All products may not be applicable to your employer group. Please check with your Group Administrator.
Section 2: Subscriber’s Information
This section should be completed by the Subscriber. **We are required to ask for your social security number in order to
meet our reporting obligations under the Affordable Care Act. *
There is additional information needed if eligible for
Medicare due to ESRD. Please contact your Group Administrator for the appropriate form.
Gender and gender identity: Univera Healthcare does not discriminate on the basis of gender identity, gender
expression or behavior. In order to ensure that you are receiving access to high quality, affordable health care based on
your individual needs, we ask that you consider completing this optional gender identity section of the application.
Univera Healthcare will not limit coverage or impose any additional cost-sharing for any otherwise-covered services that
are ordinarily available to individuals of one sex, to a transgender individual, based on the fact that an individual’s sex
assigned at birth, gender identity, gender expression or behavior or gender otherwise recorded is different from the
gender for which health care services are ordinarily available.
Section 3: Reason for enrollment or change
Select the box(es) that describe(s) the reason for this enrollment or change regarding health insurance coverage and
include the date of the event. An event is a specific occurrence, due to change in status, marriage, divorce, birth or
adoption, group's anniversary date, or rate change. Your request must be received within 30 days of the event date.
Please see your Group Administrator for events that fall outside the 30-day period. You may be required to provide
documentation of certain events.
Section 4: Cancel Information - If canceling coverage, who are you canceling coverage for?
If you are canceling coverage, complete the appropriate section for who you are canceling. List the cancel code and enter
the date(s) the coverage is to be canceled. List each applicable dependent to be canceled.
Section 5: Information about who you would like coverage for (dependent information)
Please include information about all the people who you would like coverage for.
Use an additional application or addendum if more than three dependents need coverage.
If your dependents are Medicare eligible, complete the questions regarding Medicare coverage.
Qualified guidelines for coverage include:
A legal spouse/domestic partner (An ex-spouse no longer qualifies as of the date court documents are stamped
and filed with the county clerk)
Must be under the eligible child age for your employer group including natural, adopted or stepchild(ren)
Child(ren) Only coverage is available for children up to age 26 or 29 depending on the employer group coverage.
There are additional eligibility requirements for dependents pending adoption, for which you are the legal
guardian, and/or a disabled dependent who is over the maximum dependent age. Please contact your Group
Administrator for the appropriate form.
**We are required to ask for your social security number in order to meet our reporting obligations under the Affordable
Care Act.
*
There is additional information needed if eligible for Medicare due to ESRD. Please contact your Group Administrator for
the approp
riate form.
A separate Adult Disabled Dependent application form is required for applicable dependents. Please contact your Group
Administrator for the appropriate forms.
Section 6: Other coverage information (Required)
Please include accurate information in this section. This could affect the processing of your application and/or claims.
Section 7: Release
Subscriber signature and date are required in this section. The subscriber must sign the application prior to or within 30
days of the effective date or qualifying event date.
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APP-352 (0719) U Mid/Large Group
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