Fillable Employer Application for Small Business (Dickerson Insurance Services)

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Employer Application for Small Business (Dickerson Insurance Services)

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SG.ER.17.CA 4/17
Employer Application for Small Business
To avoid processing delays, please make sure you:
1. Answer all questions completely and accurately.
2. Complete and submit the Product and Benefit Selection Form.
3. Submit the most recent billing statement listing those
currently insured/covered and current status.
4. Submit most recent wage and tax information.
5. Include a deposit check for any required premiums.
6. DO NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL.
General Information
Effective Date
Group’s Legal Name Tax ID
DBA, if applicable
Group name to appear on ID card (maximum 30 characters and spaces)
Address Start Date of Business
City State Zip Code Telephone Fax
Billing Contact / Title Telephone Email Address
Billing Address (If different)
Executive Contact / Title Telephone Email Address
Administrative / Service Contact / Title Telephone Email Address
Organization Type: Partnership C-Corp S-Corp LLC LLP
Non-Profit Sole Proprietor Other
Did you have any employees other than yourself and your spouse or registered domestic partner during
the preceding calendar year?
Yes No
Nature of Business Industry (SIC) Code
Multi-Location Group*
Yes No
# of Locations Address(es) (Use additional sheet of paper if necessary)
*If the majority of your employees are not located in your state of application, UnitedHealthcare policies and/or state law may require that your
policy be written out of a different state and/or that your benefit plans vary.
#of hours per
week to be
eligible
Classes Excluded (if applicable):
None Union
Hourly (# of hours ________ )
Non-Management
Waiting Period for New Hires (Not to exceed 90 calendar days)
1st of the month following Date of Hire
1st of the month following _______ [months] [days] of employment
Date of Hire (no waiting period)
_______ [months] [days] of employment following Date of Hire
Waiting Period for Rehire
1st month following
_______ [months] _______ [days]
Waiting Period
Waived for Initial
Enrollees
Yes No
Subject to ERISA Regulation
Yes No
(Most private sector plans are ERISA plans)
If No, please indicate appropriate category
Church (Additional information needed)
Indian Tribe – Commercial Business
Foreign Government/Foreign Embassy
Federal Government
Non-Federal Government (State, Local or Tribal)
Non-ERISA Other
Have
Workers’
Comp
Yes No
Workers’ Comp Carrier Name or Reason if no coverage Names of Owners/Partners not covered by Workers’ Comp
Names of Persons currently on COBRA/Continuation:
Name
COBRA Cal-COBRA COBRA -AB1401
Extended/Disabled COBRA
COBRA Qualifying Event
COBRA Date of Qualifying Event
Name
COBRA Cal-COBRA COBRA -AB1401
Extended/Disabled COBRA
COBRA Qualifying Event
COBRA Date of Qualifying Event
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.
CALIFORNIA
Page 1 of 4
Coverage provided by “UnitedHealthcare and Affiliates”: Check appropriate box(s) for coverage(s) selected:
Medical
o
UnitedHealthcare Insurance Company or
o
UnitedHealthcare Benefits Plan of California (Insurance Products: Navigate, Choice/Select, Choice Plus/Select Plus, Core, Non-Diff, Doctors Plan)
Medical
o
UnitedHealthcare of California (HMO)
Dental
o
UnitedHealthcare Insurance Company or
o
Dental Benefit Providers of California, Inc.
Vision
o
UnitedHealthcare Insurance Company
Administrative services provided by United Healthcare Services, Inc., OptumRx, Inc. or OptumHealth Care Solutions, Inc. Behavioral health products by U.S. Behavioral Health Plan, California (USBHPC) or United
Behavioral Health (UBH).
UnitedHealthcare Insurance Company
UnitedHealthcare of California
UnitedHealthcare Benefits Plan of California
400 -3269 8/19
SG.ER.17.CA 4/17
Questions Regarding Group Size
COBRA
State Continuation
(e.g., Cal-COBRA)
Under federal law, if your group had 20 or more employees on your payroll on at least 50% of the group’s working days of the preceding calendar year, you
must provide employees with COBRA continuation. If your group had fewer than 20 employees, you must provide State Continuation.
Medicare Primary
Plan Primary
Under federal law, if your group had 20 or more employees during 20 or more calendar weeks in the preceding calendar year, the Health Plan is primary and Medicare
is secondary. This statement does not set forth all rules governing group level Medicare status. The Group should contact their legal and/or tax advisor(s) for information
regarding other rules that may impact the Group’s Medicare status. Under federal law it is the Group’s responsibility to accurately determine its Medicare status.
Enter the Prior
Calendar Year
Average Total
Number of Employees
___________
Under Health Care Reform law, the number of employees means the average number of employees employed by the company during the preceding calendar year. An
employee is typically any person for which the company issues a W-2, regardless of full-time, part-time or seasonal status or whether or not they have medical coverage.
To calculate the annual average, add all the monthly employee totals together, then divide by the number of months you were in business last year (usually 12 months).
When calculating the average, consider all months of the previous calendar year regardless of whether you had coverage with us, had coverage with a previous carrier or
were in business but did not offer coverage. Use the number of employees at the end of the month as the “monthly value” to calculate the year average. If you are a newly
formed business, calculate your prior year average using only those months that you were in business. Use whole numbers only (no decimals, fractions or ranges).
Enter the Prior
Calendar Year Full
Time Equivalent Total
Number of Employees
___________
For purposes of determining your number of full-time equivalent employee count, the number of employees means the average number of employees employed full-time
(at least 30 hours/week in any given month), by the company on business days during the preceding calendar year.
In addition to the number of full-time employees noted above, for any month otherwise determined, include for such month the number of full-time employees divided
by the aggregate number of hours of service of all employees who are not full-time employees for the month by 120. Employers should exclude employees who were
seasonal workers who worked 120 days or fewer in the preceding calendar year.
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.
Page 2 of 4
General Information (continued)
Has the Group been insured/covered by UnitedHealthcare in the last 12 months? Yes No If yes, date coverage terminated
Name of Carrier Coverage Begin Date Coverage End date
Current Medical Carrier
None
Current Dental Carrier
None
Current Vision Carrier
None
UnitedHealthcare’s Leave of Absence (LOA) Policy; Eligibility for Medical Coverage
If the employee is on an employer approved leave of absence and the employer continues to pay required medical premiums, the coverage will remain in force for: (1) No longer than
13 consecutive weeks for non-medical leaves (i.e. temporarily laid-off). (2) No longer than 26 consecutive weeks for a medical leave. Coverage may be extended for a longer period
of time, if required by local, state or federal rules.
If the employee’s medical coverage terminates under this LOA policy, the employee may exercise the rights under any applicable Continuation of Medical Coverage provision or the
Conversion of Medical Benefits provision described in the Certificate of Coverage.
Do you continue medical coverage during a leave of absence (not including state continuation or COBRA coverage)?
___ Yes, we continue medical coverage during an approved leave of absence for full time* employees (as defined below).
___ No, we do not offer medical coverage during a leave of absence.
Participation
# Employees Applying for: # Employees Waiving for: Contribution Employer % Employer % for Dep
# Full-Time (30 hours per week over the
course of a month)
Eligible Employees Enrolling in CA
# Part-Time (20-29 Hours)
Eligible Employees Enrolling in CA
# Full-Time (30+ Hours)
Eligible Employees Enrolling Outside of CA
# Part-Time (20-29 Hours)
Eligible Employees enrolling Outside of CA
# Employees in Waiting Period
(Not exceed 90 calendar days)
Total # Employees Waiving
# Ineligible Employees
(other than noted above)
Total # Employees
Medical Medical Medical
Dental Dental Dental
Vision Vision Vision
Other Other Other
SG.ER.17.CA 4/17
Important Information
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)
Yes
No
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)?
Yes
No
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
employee(s)?
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.
Yes
No
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
Yes
No
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.
SG.ER.17.CA 4/17
Page 4 of 4
©2015 United HealthCare Services, Inc.
PCA734926-001
Producer Information (if applicable)
Writing Producer Name Writing Producer SSN
Holds Current Appointment with
UnitedHealthcare
Payee CA License # Payee CA License Expiration Date Writing Agent’s License # Writing Agent’s License Expiration
Date
All Payments to Payee Code CRID Code Tax ID# If more than one Producer*,
Split
_______%
Street Address City State ZIP Code
Producer Phone # Producer Fax Number Producer Email Address
The contents of this application were fully explained during a meeting with the Group submitting this application. Coverage, eligibility, the effect of misrepresentations, and termination provisions
were discussed.
Please Check One of the Following (Required):
I attest that I assisted the applicant in submitting this application to UnitedHealthcare. To the best of my knowledge, the information on the application is complete and accurate. I explained to
the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information and that, to the best of my knowledge, the applicant understood the explanation.
I attest that I did not advise or assist the applicant whatsoever in providing answers or responses to any of the questions contained in the application.
IMPORTANT NOTICE: If you willfully state as true any material fact you know to be false, you are subject to a civil penalty of up to ten thousand ($10,000) pursuant to California Insurance Code
Section 10119.3 and California Health and Safety Code Section 1389.8.
Producer Signature
Date
*If more than one Producer, provide the second Producer’s information on an additional sheet of paper.
General Agent Information (if applicable)
General Agent General Agent Tax ID# Phone # Franchise Code
Street Address City State ZIP Code
Contact Name Email Address
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.
BINDING ARBITRATION
I AGREE AND UNDERSTAND THAT ANY AND ALL DISPUTES, INCLUDING CLAIMS RELATING TO THE DELIVERY OF SERVICES
UNDER THE PLAN AND CLAIMS OF MEDICAL MALPRACTICE (THAT IS, AS TO WHETHER ANY MEDICAL SERVICES
RENDERED UNDER THE HEALTH PLAN WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY
OR INCOMPETENTLY RENDERED), EXCEPT FOR CLAIMS SUBJECT TO ERISA, BETWEEN GROUP/COMPANY, MEMBERS
AND ENROLLEES (INCLUDING ANY HEIRS OR ASSIGNS) AND UNITEDHEALTHCARE OF CALIFORNIA, UNITEDHEALTHCARE
OR ANY PARENTS, SUBSIDIARIES OR AFFILIATES, SHALL BE DETERMINED BY SUBMISSION TO BINDING ARBITRATION
BY A SINGLE NEUTRAL ARBITRATOR IN ACCORDANCE WITH THE COMMERCIAL RULES OF THE AMERICAN ARBITRATION
ASSOCIATION. ANY SUCH DISPUTE WILL NOT BE RESOLVED BY A LAWSUIT OR RESORT TO A COURT PROCESS, EXCEPT
AS THE FEDERAL ARBITRATION ACT PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. ALL PARTIES TO
THIS AGREEMENT ARE GIVING UP THEIR CONSTITUTIONAL RIGHTS TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT
OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF BINDING ARBITRATION IN ACCORDANCE WITH
CALIFORNIA ARBITRATION LAW (TITLE 9 OF THE CALIFORNIA CODE OF CIVIL PROCEDURE §1280 ET SEQ.) EXCEPT WHERE
SUCH LAWS MAY BE PREEMPTED BY FEDERAL LAW INCLUDING, BUT NOT LIMITED TO, THE FEDERAL ARBITRATION ACT,
9 U.S.C. § 1 ET SEQ. IF A CLAIM FOR MEDICAL MALPRACTICE SEEKS TOTAL DAMAGES OF $50,000 OR LESS, THE CLAIM
OR DISPUTE SHALL BE DECIDED BY A SINGLE NEUTRAL ARBITRATOR WHO SHALL HAVE NO JURISDICTION TO AWARD
MORE THAN $50,000. IF THE PARTIES ARE UNABLE TO AGREE TO THE SELECTION OF A SINGLE ARBITRATOR, THE
METHOD FOR THE APPOINTMENT OF THE ARBITRATOR IN CALIFORNIA CODE OF CIVIL PROCEDURE SECTION 1281.6
SHALL BE UTILIZED.
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Signature (Required) Date (Required)
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Employer Application for Small Business (Dickerson Insurance Services)

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