I understand that the Evidence of Coverage, Certiﬁcate of Coverage or Summary Plan Description, and other documents, notices and
communications regarding the coverage indicated on this application, herein referred to as “Disclosure Materials,” will be transmitted
electronically to the Group/Company.
I acknowledge and aﬃrmatively agree, on behalf of the Group/Company, to provide the applicable Disclosure Materials provided by
UnitedHealthcare and Aﬃliates that contain information regarding beneﬁts, services, exclusions, limitations and terms of the enrollee’s
health care coverage in electronic form and/or hard copy to enrolled members in accordance with California and federal laws, so as to
aﬀord the enrollee full and fair disclosure.
I represent that, to the best of my knowledge, the information I have provided in this application – including information regarding
qualiﬁed beneﬁciaries and dependents who have elected continuation under COBRA or state continuation laws – is accurate and
truthful. I understand that UnitedHealthcare and Aﬃliates will rely on the information I provide in determining eligibility for
coverage, setting premium rates, and other purposes. If UnitedHealthcare can demonstrate you committed an act or practice
that constituted fraud or an intentional misrepresentation of a material fact, it may result in rescission of the group/company
policy/agreement, termination of coverage, or increase in premiums retroactive to the original eﬀective date of the agreement/
policy. UnitedHealthcare will issue a written notice via regular certiﬁed mail at least 30 days prior to the eﬀective date of the
rescission explaining the basis for the decision of rescission and your appeal rights. After 24 months following the issuance of
the agreement/policy, UnitedHealthcare will not rescind the agreement/policy for any reason, and will not cancel the agreement/
policy, limit any of the provisions of the agreement/policy, or increase premiums on the agreement/policy due to any omissions,
misrepresentations or inaccuracies in the application form, whether willful or not. Group/Company will receive any notices for failure
to pay and/or termination in writing. In accordance with the Group Subscriber Agreement/Policy, Group is delegated to provide notice
of termination to each subscriber/insured person at the subscriber’s/insured person’s current address. For nonpayment of premiums,
UnitedHealthcare and Aﬃliates will send a notice of termination with appeal rights directly to the member.
The falsity of any statement in the application for any Policy/Group Subscriber Agreement shall not bar the right to recovery under the
Policy/Group Subscriber Agreement unless such false statement was made with actual intent to deceive or unless it materially aﬀected
either the acceptance of the risk or the hazard assumed by the insurer/health care service plan.
UnitedHealthcare disclosure regarding producer compensation: In some instances, we pay brokers and agents (referred to collectively
as “producers”) compensation for their services in connection with the sale of our products, in compliance with applicable law. In certain
states, we pay “base commissions” based on factors such as product type, amount of premium, group size and number of employees.
These commissions, if applicable, are reﬂected in the premium rate. In addition, we may pay bonuses pursuant to programs established to
encourage the introduction of new products and provide incentives to achieve production targets, persistency levels, growth goals or other
objectives. Bonus expenses are not directly reﬂected in the premium rate but are included as part of the general administrative expenses.
Please note, we also make payments from time to time to producers for services other than those relating to the sale of policies/agreements
(for example, compensation for services as a general agent or as a consultant).
Producer compensation may be subject to disclosure on Schedule A of the ERISA Form 5500 for customers governed by ERISA. We
provide Schedule A reports to our customers as required by applicable federal law.
For speciﬁc information about the compensation payable with respect to your particular policy/agreement, please contact your producer.
Questions Regarding Group Size (continued)
Do you currently utilize the services of a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), Staﬀ Leasing Company, HR Outsourcing
Organization (HRO), or Administrative Services Organization (ASO)?
Is your group a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), or other such entity that is a co-employer with your client(s) or client-site
If you answered Yes, then by signing this application you agree with the certiﬁcation in this section.
I hereby certify that my company is a PEO, ELC or other such entity and that only those employees that are the corporate employees of my company, and not my
co-employees, are permitted to enroll in this group policy. If my group at any point after I sign this application determines that the group will provide coverage to the
co-employees under the group’s plan, I understand that UnitedHealthcare will not cover the co-employees under this group policy.
Does your group sponsor a plan that covers employees of more than one employer?
If you answered Yes, then indicate which of the following most closely describes your plan:
Professional Employer Organization (PEO) Governmental
Multiple Employer Welfare Arrangement (MEWA) Church
Taft Hartley Union Employer Association
Do you have common ownership with any other businesses? If you own multiple companies, or a parent-subsidiary relationship exists between your company and
another, this may indicate common ownership of businesses.
Page 3 of 4
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.