Fillable Form 800: Medical / Dental / Life / (Dickerson Insurance Services)

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Form 800: Medical / Dental / Life / (Dickerson Insurance Services)

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Date of Birth (MM/DD/YYYY)
Full-Time Employment Date (MM/DD/YYYY)
Select one
Enrollin
g
For?
Last Name
First Name
Social Security #
Date of Birth
Gende
r
Life only
Disabled?
Spouse/Domestic Partne
r
Child 1 Child 2 Child 3Employee
(1 of 5)
Personal Information
Medical / Dental / Life / Vision
Enrollment Application
Company Name
Employee First Name
M.I.
Employee Social Security #
Gender
M F
Status
City
County
Physical Address (Do not use P.O. Box) Apt. #
E-mail Address
Mailing Address
(if different from above)
Enrollment Information
Relationship to Emplo
y
ee
Spouse
Domestic
Partner
Complete this section ONLY if you are electing medical, dental and/or vision for yourself and dependents.
B
(exclude any orientation periods, if applicable)
Social Security # required! Social Security # required! Social Security # required! Social Security # required!
MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY
(Complete only if over age 26)
To enroll more dependents, complete sections A & B on an additional application.
COBRA Applicants
Please check
COBRA type
Indicate Qualifying/Triggering Event
Termination of employment Child no longer eligible Medicare entitlement
Reduction of hours Divorce/legal separation Death of employee
Male Female Male Female Male Female Male Female
Yes No Yes No Yes No
Apt. #
City
Married Single Domestic Partner
New Business New Hire New Renewal New COBRA Qualifying/Triggering Event
A
Medical
Dental
Vision
Medical
Dental
Vision
Medical
Vision
Dental
Medical
Dental
Vision
Medical
Dental
Vision
Employee Job Title
Home Phone # (XXX) XXX-XXXX
- -
State ZIP Code
CountyState ZIP Code
Date of Qualifying/Triggering Event
(MM/DD/YYYY)
COBRA
Cal-COBRA
PLEASE SIGN AND DATE APPLICABLE SECTIONS INSIDE APPLICATION
COMPLETE WAIVER SECTION ON PAGE 4 IF YOU OR ANY OF YOUR DEPENDENTS ARE NOT ENROLLING.
COMPLETE AN EMPLOYEE CHANGE REQUEST FORM IF YOU ARE AN EXISTING MEMBER AND NEED TO MAKE CHANGES.
FOR PRIMARY CARE PHYSICIAN CHANGE ONLY, PLEASE CONTACT YOUR HEALTH PLAN DIRECTLY.
721 South Parker, Suite 200, Orange, CA 92868
(
800
)
558-8003 www.calchoice.com
•
Group #
Employee Last Name
CC 0310 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
22883
1000
3000 3500 4000 5000
MET100 MET185
(2 of 5)
Print Employee Name
Group #
If you are listing more than one primary beneficiary or more than one secondary beneficiary, please enter the percentage of the insurance proceeds that
each individual should receive. The percentage of insurance proceeds must equal 100% for each type of beneficiary (primary or secondary). No secondary
beneficiaries will be entitled to any part of the insurance proceeds if any primary beneficiary is living at the time of death of the insured.
Dental Coverage
Dentist Name / Office ID#
(If left blank or dentist is unavailable, one will be assigned)
MetLife and SmileSaver DHMO plans require
selection of a family dentist. Upon receipt of dental ID
cards, you may elect other dentists for dependents.
Premium Only Plan (P.O.P.)
I want my portion of eligible insurance premiums paid on a pre-tax basis
Check if you would like a dentist assigned
Check if dentist chosen is current provider
†
†
*HSA Qualified High Deductible Plan
Vision Coverage – IMPORTANT: Please select ONE benefit plan below
Voluntary EyeMed (provided by Ameritas)* Voluntary VSP (provided by Ameritas)* Vision One Discount Plan (No Charge)
*Employee is responsible for 100% of this cost if selected for coverage
Spouse/Domestic Partne
r
Child 1
Child 2 Child 3
Medical Benefit -
IMPORTANT: Please select ONE benefit plan from the metal tier(s) shown on your Enrollment Worksheet.
Life Insurance
Sections A, B & E of this a
pp
lication must be com
p
leted for all O
p
tional Benefits.
Beneficiar
y
Name
(
s
)
Last Name First Name M.I. Date of Birth
Relationship to You
(i.e. spouse, friend, child)
***Percentage
Type of
Beneficiary
Primary
Secondary
Primary
Secondary
Primary
Secondary
***
D
Optional Benefits -
A
sk your health plan administrator if any of the optional benefits below are being offered by your employer.
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
***
D
C
Check here if you would like your Health Plan to assign you a Primary Care Physician.
Primary Care Physician (PCP) is not required for Kaiser Permanente, EPO and PPO benefit plans. If a PCP is not contracted with your selected Health
Plan prior to enrolling or if a PCP is not listed, one will automatically be assigned to you.
Primary Care Physician**
Yes NoYes NoYes NoYes NoYes No
Current Patient?
Provider ID#
Provider City
**
Employee Spouse/Domestic Partne
r
Child 1
Child 2 Child 3
CC 0310A 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
SmileSaver DHMO Ameritas PPO
3000
WESTERN HEALTH
ADVANTAGE
UNITED
HEALTHCARE
SHARP
KAISER
PERMANENTE
HEALTH NET
ANTHEM
BLUE CROSS
HEALTH PLAN
BRONZE
SILVER
GOLD
PLATINUM
SUTTER
HEALTH PLUS
HMO A
EPO A
HMO A
HMO A
HMO B*
HMO A
HMO B*
HMO B
HMO C*
HMO A
EPO A
HMO F
HMO B
HMO A
HMO B
HMO B
HMO A
HMO B
HMO C*
HMO B
HMO A
HMO C*
PPO B
PPO A HMO A
HMO B
HMO A
HMO B
HMO C
HMO B
HMO A
HMO B
HMO A
HMO B
HMO A
HMO B
HMO A
PPO B
PPO A
PPO D
PPO C
HMO A
HMO C
HMO A
HMO A
HMO B
HMO A
HMO B
HMO A
HMO C
HMO A
HMO B
EPO B*
HMO C* HMO C
HMO C
HMO C
HMO D*
HMO D*
HMO C
HMO D
HMO C
HMO C
HMO A
HMO D
HMO B
HMO E
HMO D
HMO E
OSCAR
EPO A*
EPO B
EPO A*
EPO B
EPO A
EPO B
EPO C
EPO A
EPO B
HMO A
EPO D
EPO C
HMO B
HMO B
PPO A*
PPO B*
PPO C
PPO E
EPO C
EPO D
HMO E
HMO F
HMO G
HMO H
HMO B HMO E
HMO D
HMO F
HMO G
HMO H
HMO I
HMO J
HMO K
HMO E
HMO E
HMO D
HMO G
HMO F
HMO C
MetLife DHMO
†
22883
Today's Date (MM/DD/YYYY)
Your Legal Acknowledgement and
Mandatory Binding Arbitration Agreement
(Read, sign and date where indicated)
E
(3 of 5)
Group #
Print Employee Name
I declare under the penalty of perjury under the laws of the state of California that the following statements are true, correct and pertain to the
employer named on this application, myself and my dependents named on this application.
California law prohibits an HIV test from being required or used by health care service plans as a condition of obtaining coverage.
• I am either actively, permanently working for the employer and considered eligible by my employer because I work either 20+ or 30+ hours per week, or I
am an eligible COBRA/Cal-COBRA participant.
• I am not a temporary, seasonal, per diem, 1099 or substitute employee or insured by or eligible to be insured by the employer’s union policy.
• My children’s dates of birth are accurate. My children are born to me or my spouse/domestic partner, or legally adopted, or a nontemporary legal ward,
and/or have an established parent-child relationship with me or my spouse/domestic partner. I understand that I am required to notify CaliforniaChoice
when an established parent-child relationship ceases to exist.
I understand that the preceding statements are subject to audit at any time and agree to provide CaliforniaChoice with any and all information necessary to
prove the above statements.
I understand that any persons, business or health plan that suffers a loss because of false-declarations contained in this statement may take legal action
against me to recover their losses.
• The representations made are the basis upon which coverage may be issued.
• The coverage may be cancelled or the employer’s contract rescinded because of the performance of an act or practice constituting fraud or making of an
intentional misrepresentation of a material fact to an insurance company for the purposes of defrauding the company.
• I have READ, UNDERSTAND and ATTEST that I myself and my dependents have met all of the eligibility requirements.
MANDATORY BINDING ARBITRATION
I understand that, if I select a Health Plan that uses mandatory binding arbitration to resolve disputes, I am agreeing to
arbitrate claims that relate to my or a dependent's membership in the Health Plan (except for Small Claims Court cases
and claims that cannot be subject to binding arbitration under governing law). I understand
that any dispute between
myself, my heirs, relatives, or other associated parties on the one hand and the Health Plan, any contracted health
care providers, administrators, or other associated parties on the other hand for alleged violation of any duty arising
out of or related to membership in the Health Plan, including any claim for medical or hospital malpractice (a claim that
medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for
premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be
decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable
law provides for judicial review of arbitration proceedings. I agree
to give up our right to a jury trial and accept the use
of binding arbitration. I understand
that the full arbitration provision is in the Health Plan's coverage document, which
is available for my review.
Employee SIGN HERE FOR MEDICAL, DENTAL, LIFE OR VISION COVERAGE
Print Name
My signature acknowledges that I have read Section E, the applicable mandatory binding arbitration of the plan I selected in Section C and my
decision to enroll in the medical, dental, life or vision coverage that I selected in Sections C and D.
By submitting this signed application, I agree and understand that the health plan I have chosen through the CaliforniaChoice program shall
automatically have a lien on any payment of monies from any source, for services rendered in conjunction with an injury caused by the acts or omissions of a
third party.
I agree
for myself and my dependents to be bound by the benefits, copays, deductibles, exclusions, limitations and other terms of the health plan’s small
group contract.
I authorize my physician, healthcare provider, hospital, clinic or other medically related facility to furnish my, and my dependent’s, protected health
information, including medical records, to the health plan I have chosen through the CaliforniaChoice program or its authorized agents for the purpose of
review, investigation, or evaluation of an application or claim, and for quality assurance and utilization review. I authorize CaliforniaChoice and the health plan
I have chosen, and their agents, designees or representatives, to disclose to a hospital, health plan, insurer or healthcare provider any protected health
information if such disclosure is necessary to allow the performance of any of those activities. This authorization shall become effective immediately and shall
remain in effect for up to 30 months from the date the authorization was signed. I understand that I, or a person authorized to act on my behalf, is entitled to
receive a copy of this authorization form.
I have read and understand the information provided to me pertaining to the Premium Only Plans and the tax consequences.
A
ll statements and answers I have given are true and complete. I understand it is a crime to knowingly perform an act or practice constituting fraud or make
an intentional misrepresentation of material fact to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment,
fines or a denial of insurance benefits. I understand all benefits are subject to conditions stated in the Group Contract and coverage documents. If my plan is
rescinded or canceled, I will receive from my insurer a notice at least 30 days prior to the effective date of the rescission explaining the reasons for the
intended rescission and my right to appeal that decision to the Commissioner of Insurance pursuant to subdivision (b) of Section 10273.4 of the California
Insurance Code. Notwithstanding subdivision (a) of Section 10273.4 or any other provision of the law, I understand that after 24 months following the issuance
of my health plan or insurance policy, my insurer may not rescind my health plan or insurance policy for any reason, and shall not cancel my health plan or
insurance policy, limit any provisions of the health plan or policy, or raise premiums due to any omissions, misrepresentations, or inaccuracies in the
application for, whether willful or not.
CC 0310B 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
®
22883
Today's Date (MM/DD/YYYY)
Employee SIGN HERE TO WAIVE COVERAGE
(4 of 5)
Personal Information
IMPORTANT!
MEDICAL / DENTAL WAIVER
Complete this page only if you DO NOT WANT MEDICAL OR DENTAL COVERAGE for yourself and/or your eligible dependents. If
offered by your employer, the life coverage benefit cannot be waived and you are required to complete an Enrollment Application.
Chiropractic coverage cannot be waived when enrolling for medical coverage.
Company Name
Employee Last Name
Employee First Name
Group #
Type of Waiver
Reason
Signature
I have been offered coverage by my employer, but at this time I wish to DECLINE coverage as follows
1)
2)
Medical for
Dental for
Carrier Name
1)
Required only if employee waiving coverage - not required if waiving coverage for dependents only
Other Group Coverage
Medicare
Medi-cal
Individual Policy
Other Reason
Reason waiving Medical
(explanation required)
2)
Reason waiving Dental
I understand that by failing to elect coverage now, CHOICE Administrators Insurance Services, Inc. will require me to wait to enroll until my
employer group's next open enrollment period, unless I experience a qualifying/triggering event that would allow me to enroll for coverage prior
to open enrollment.
I understand that by failing to elect DENTAL coverage now, CHOICE Administrators Insurance Services, Inc. can also impose a 6 month
pre-existing condition exclusion, both of which would begin at the time of my later decision to elect DENTAL coverage.
I also understand that if my employer is offering life coverage, I CANNOT WAIVE LIFE COVERAGE.
This waiver provision will not apply if: 1) Court orders coverage of a spouse or child and the request for enrollment occurs within 60 days of the
court order; or 2) Employee meets ALL of the following: A) Was covered under another employer-sponsored health plan at the time of initial
eligibility; B) Has added a new dependent as a result of marriage, domestic partnership, birth, adoption, or placement for adoption or has assumed a
p
arent-child relationship and if enrollment is requested within 60 days after the marriage, domestic partnership, birth, adoption or placement for
adoption or has assumed a parent-child relationship OR employee or eligible dependents loses minimum health care coverage, for any reason other
than due to failure to pay premiums, fraud, or intentional misrepresentation of material fact; C) Requests enrollment within 60 days of loss of
coverage.
C
D
B
A
Print Name
Myself and Dependents
Spouse Child(ren)
Myself and Dependents
Spouse
Child(ren)
Domestic Partner
Domestic Partner
Employee Social Security #
Company Phone # (XXX) XXX-XXXX
- -
Other Group Coverage
Medicare
Medi-cal
Individual Policy
Other Reason
Carrier Name
(explanation required)
CC 0310C 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
®
22883
Validate My Form
(5 of 5)
Family Coverage
Eligibility Requirements
721 South Parker, Suite 200, Orange, CA 92868
(
800
)
558-8003 www.calchoice.com
•
CC 0310D 12/2020 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators, Inc.
Who can be covered?
If all required documentation is received
before the 16th day of the month of
marriage, premiums are charged for the
full month and coverage begins on the date
of marriage.
If all required documentation is received on
or after the 16th day of the month of
marriage, coverage begins on the 1st of
the month following
the date of receipt.
Effective dates Requirements that MUST be met
■ New spouse must be legally married to the employee
■ New stepchild must also meet the dependent children requirements listed below
New Spouse/
New Stepchild
Birth/Adoption/
Legal Guardianship/
Eligible Dependent
Child
If birth/date of placement occurred
before the 16th of the month, coverage
begins on the first day of the month of the
date of birth/placement.
If birth/date of placement occurred on the
16th or after, child is automatically covered
at no cost under Subscriber between date
of birth/placement and the first of the
following
month. Coverage for the
dependent begins on the first of the month
following the birth/date of placement.
MEDICAL, CHIRO, VISION and METLIFE & SMILESAVER DENTAL Dependent
eligibility:
■ Born to, a stepchild or legal ward of, adopted by, or have an established
parent-child relationship with the eligible employee, employee spouse or
domestic partner
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
AMERITAS DENTAL Dependent eligibility:
■ Born to, a stepchild or legal ward of, adopted by, or have an established
parent-child relationship with the eligible employee, employee spouse or
domestic partner
■ Financially dependent upon the employee per IRS guidelines
■ Unmarried or not involved in a domestic partnership
■ Under age 26 (unless disabled, disability diagnosed prior to age 26)
Disabled Dependents:
Dependents who are incapable of self-support
because of continuous mental or physical disability that existed before the age
limit are eligible for coverage until the incapacity ends. Documentation of
disability will be requested. Once the child reaches the age limit for coverage,
verification of eligibility will occur annually at the child’s birthday.
Dependents must meet all requirements listed in order to be
eligible for enrollment
Both have filed a duly executed Declaration of Domestic Partnership with the
Secretary of State and will provide copies to CaliforniaChoice within 60 days
of its issue.
A
gree to notify CaliforniaChoice immediately upon termination of domestic
partnership.
Children of Domestic Partner must also meet the dependent children
requirements listed above
■
■
Domestic Partner/
Child of Domestic
Partner
During Initial Enrollment or Group’s Annual
Renewal:
Coverage begins on group’s effective date.
Involuntary Loss of Other Coverage:
Domestic Partner can be added outside of
Renewal only if he/she loses other
coverage involuntarily. Coverage is
effective the first of following month.
Mid-Year Addition:
Mid-year additions of a
domestic partner will require a
state-stamped copy of the Declaration of
Domestic Partnership from the California
Secretary of State within 60 days of
issuance. If domestic partners have filed a
Declaration of Domestic Partnership and
have not yet received a copy from the state,
a signed Affidavit of Domestic Partnership
will be accepted. Domestic Partners agree
to provide a copy of the Declaration of
Domestic Partnership within 60 days of
issuance. If all required documentation is
received before the 16th day of the month in
which the domestic partnership was
established, premiums are charged for the
full month and coverage begins on the date
of the event. If all required documentation is
received on or after the 16th day of the
month in which the domestic partnership
was established, coverage begins on the
1st of the month following
the date of
receipt.
Employee and Domestic Partner must meet all requirements
listed in order to be eligible for enrollment
®
For a Domestic Partner to qualify, Employee and Domestic Partner must:
Employee and Domestic Partner must meet all requirements
listed in order to be eligible for enrollment
22883
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Form 800: Medical Dental Life (Dickerson Insurance Services)

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Completed 1 June 2021

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