Fillable Form/Waiver of Coverage Small Business Employee Enrollment (Dickerson Insurance Services)

Fill Online, Printable, Fillable, Blank Form/Waiver of Coverage Small Business Employee Enrollment (Dickerson Insurance Services) Form

Use Fill to complete blank online DICKERSON INSURANCE SERVICES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form/Waiver of Coverage Small Business Employee Enrollment (Dickerson Insurance Services)

On average this form takes 62 minutes to complete

The Form/Waiver of Coverage Small Business Employee Enrollment (Dickerson Insurance Services) form is 6 pages long and contains:

  • 0 signatures
  • 156 check-boxes
  • 175 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Dickerson Insurance Services forms online.

BROWSE DICKERSON INSURANCE SERVICES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Instructions
Complete the information requested in each section
according to the guidelines provided below. Please be
thorough and ll out all sections that apply. Submit the
completed enrollment form to your employer for processing.
Section A: Employee Information
• Please complete all information requested;
• If enrolling in a UnitedHealthcare of California HMO plan,
you must select a Primary Care Physician (PCP). Select
a PCP from the Provider Directory for yourself and each
of your family members by writing the PCP name and
Provider Number in the area provided. You may choose a
different PCP for each member of your family.
PCP selection is only required if a UnitedHealthcare
SignatureValue
TM
(HMO), UnitedHealthcare
SignatureValue
TM
Advantage, SignatureValue
TM
Harmony,
UnitedHealthcare SignatureValue
TM
Alliance, or
UnitedHealthcare SignatureValue
TM
Focus plan is selected.
If you do not select a PCP when selecting one of these
plans, a PCP will be automatically assigned to you.
• If enrolling in a Dental HMO Plan, select a Primary Care
Dentist (PCD) from the Dental Provider Directory for
yourself and each of your family members. Write the PCD
name and Provider Number in the area provided. You may
choose a different Primary Care Dentist for each enrolling
member, however PCDs cannot be automatically assigned
and are only required for the Dental HMO plans.
Section B: Dependent Information
• Complete all information for each enrolling dependent,
including any enrolling dependent’s Social Security
number.
• For each dependent enrolling in a UnitedHealthcare of
California HMO Plan, select a Primary Care Physician
(PCP) from the Provider Directory by writing the PCP
name and Provider Number in the area provided. You may
choose a different PCP for each member in your family.
If you do not select a PCP when selecting one of these
plans, a PCP will be automatically assigned to you.
• For each dependent enrolling in a Dental HMO Plan,
select a Primary Care Dentist from the Dental Provider
Directory. Write the PCD name and Provider Number in
the area provided. You may choose a different Primary
Care Dentist for each enrolling member, however PCDs
cannot be automatically assigned and are only required for
the Dental HMO plans.
• Verify that spousal and domestic partner coverage is
available through your Employer.
• Dependents are covered to age 26 and no full-time student
status is required.
Section C: Product Selection
• Benet offerings are dependent on your employer
selections. Check with your employer for available plan
options being offered to you.
• Check the box for each plan in which you or your
dependents are enrolling.
• All enrolling family members must select the same medical
and dental plan.
• When selecting a UnitedHealthcare or UnitedHealthcare
Benets Plan of California medical plan, write the three-
digit or four-digit plan code of your selection in the space
provided. For example: Plan Code GN-3.
• When selecting a UnitedHealthcare of California (HMO)
plan, write the description of the plan you selected. For
example: UnitedHealthcare SignatureValue
TM
20-40/250d.
Section D: Other Medical Insurance/Health Plan
Coverage Information
• If you, your spouse/domestic partner, or any dependent
will be covered under any other medical insurance plan/
health plan, including Medicare, on the day this insurance/
health plan coverage begins, please complete this section.
If no other medical plan/coverage exists, please indicate
by checking NO.
Small Business Employee Enrollment
Form/Waiver of Coverage
California
Section E: Waiver of Coverage
• You can waive the health care services coverage
provided through your employer for yourself and/or any
of your family members. If waiving coverage for yourself
and/or any family member, a signature is required in this
section. Please read the entire section carefully, sign
and date in ink, and return the form to your employer for
processing.
Section F: Application Signature
• Review this section carefully, sign and date.
Section G: Binding Arbitration – Applicable to
UnitedHealthcare of California (HMO) Enrollees Only
• Review this section carefully, sign and date.
Section H: Census Information
• Check all boxes that apply. The information collected in
this section will only be used to help communicate
with enrollees and inform them of specic programs to
enhance their well-being. This information will not be
used in the eligibility process.
Fax to 1-866-372-1316 or online:
Select, Select Plus, Core, Navigate, Non-Differential
PPO, and HSA Medical, Dental, Vision and Life –
www.employereservices.com
Employer Instructions
Complete the top section of the Employee Enrollment Form and conrm all required information has been completed by the
employee. Submit enrollment/eligibility changes and terminations, based on the plan in which the employee is enrolling:
For new business groups or additional questions, contact your broker or local UnitedHealthcare sales ofce.
SignatureValue, SignatureValue Advantage, Focus, Harmony,
and Alliance Medical Only – www.uhc.com (Employer tab)
Rev. 10/1/2019
To speed the enrollment process, please be
thorough and ll out all sections that apply.
(DO NOT STAPLE)
To Be Completed by Employer
Group Name/Number
Requested Effective Date of
Insurance / Health Plan Coverage /
Date of Change
/ /
Reason for Application
New Group Plan New Hire
Dependent Add/Delete
Annual Open
Enrollment
Change Name/Address Late Enrollee
Termination Date:
___
/
___
/
___
Waiving Coverage
(Complete Sections A and E)
Life Event/Date ____________________
Status Change ____________________
Other ___________________________
________________________________
Employee Type (check all that apply)
Active Union Non-Union Retired
Hourly Salary Other
COBRA Cal-COBRA
Start Date
__
/
__
/
__
End Date
__
/
__
/
__
Indicate Qualifying Event _______________
___________________________________
Original Qualifying Event Date
Start Date
__
/
__
/
__
End Date
__
/
__
/
__
Date of Hire / /
Position/Title
Hours Worked Per Week
B. Dependent Information
List All Enrolling (attach sheet if necessary)
Name (Last, First, M)
Sex
M
F
Relationship
3
Spouse/
Domestic
Partner
Date of Birth
_______/_______/_______
Social Security Number
Address (if different from Employee)
Preferred Language
English Spanish Chinese Vietnamese
Korean Other
____________________________
Primary Care Physician
1
Name: _________________________________________________
Address: ___________________________________________________________________
ID#
Existing Patient Medical Yes No
Primary Care Dentist
2
Name: __________________________
ID#: ______________________________________________
Existing Patient Dental Yes No
A. Employee Information
Complete All Sections
If you are waiving coverage, please complete only Sections A and E
Last Name First Name MI Social Security Number Home Phone/Cell
Work Phone
Address
Apt #
City State ZIP Code Email Address
Date of Birth
/ /
Sex
M F
Marital Status Single Married Divorced
Widowed Domestic Partner
Have you or your dependents ever been a
UnitedHealthcare member? Yes No
Preferred Language: English Spanish Chinese Vietnamese Korean Other ______________________________
______
Primary Care Physician
1
  Name: _____________________________________
Address ________________________________________________________
ID#
Existing Patient Medical Yes No
Primary Care Dentist
2
Name: ______________________________
ID#: _________________________________________________
Existing Patient Dental Yes No
Small Business
Employee Enrollment Form
CALIFORNIA
UnitedHealthcare Insurance Company
UnitedHealthcare of California
UnitedHealthcare Benets Plan of California
l l l l – l l l – l l l l l
Name (Last, First, M)
Sex
M
F
Relationship
3
Dependent
Date of Birth
_______/_______/_______
Social Security Number
Address (if different from Employee)
Please check box when selecting HMO health plan coverage:
Permanently disabled and age 26 or older
4
Yes
No
Preferred Language
English Spanish Chinese Vietnamese
Korean Other
____________________________
Primary Care Physician
1
Name: _________________________________________________
Address: ___________________________________________________________________
ID#
Existing Patient Medical Yes No
Primary Care Dentist
2
Name: __________________________
ID#: ______________________________________________
Existing Patient Dental Yes No
l l l l – l l l – l l l l l
IMPORTANT: (1) Please use the UnitedHealthcare Provider Directory to select a Primary Care Physician for yourself and each of your covered dependents
for products requiring a Primary Care Physician designation. (2) Please use the Dental Directory to select a Primary Care Dentist for yourself and each of
your covered dependents for products requiring a Primary Care Dentist designation. (3) For court-ordered dependent, legal documentation must be attached.
(4) Applicable to HMO health plan coverage selection: If you answered “Yes” for Disabled and the dependent child is 26 years of age or older, unmarried,
chiey dependent upon subscriber for support and is not able to be self-supporting because of a physically or mentally disabling injury, illness or condition,
please attach a medical certication of disability.
SG.EE.16.CA 4/15 400-3688 1/20
SG.EE.16.CA 4/15
Subscriber Last, First Name _________________________________________ SSN ____________________________________
Person Medical Dental Vision
Medical Plan and Dental Plan Selection – Write in the Plan Code or Description
of Medical and Dental plan in which you wish to enroll.
Employee
Spouse/Domestic Partner
Dependents
Medical Plan Code/Description:
___________________________________________________________________
Dental Plan Code/Description:
___________________________________________________________________
C. Product Selection
Please check the box for each plan you or your dependents are enrolling in. Benefit offerings are
dependent on employer selections.
Coverage provided by “UnitedHealthcare and Afliates”:
Check appropriate box(s) for coverage(s) selected:
Medical UnitedHealthcare Insurance Company or UnitedHealthcare Benets Plan of California (Insurance Products: Navigate, Choice/Select,
Choice Plus/Select Plus, Core, Non-Diff, Doctors Plan)
Medical UnitedHealthcare of California (HMO)
Dental UnitedHealthcare Insurance Company or Dental Benet Providers of California, Inc.
Vision 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).
Name (Last, First, M)
Sex
M
F
Relationship
3
Dependent
Date of Birth
_______/_______/_______
Social Security Number
Address (if different from Employee)
Please check box when selecting HMO health plan coverage:
Permanently disabled and age 26 or older
4
Yes
No
Preferred Language
English Spanish Chinese Vietnamese
Korean Other
____________________________
Primary Care Physician
1
Name: _________________________________________________
Address: ___________________________________________________________________
ID#
Existing Patient Medical Yes No
Primary Care Dentist
2
Name: __________________________
ID#: ______________________________________________
Existing Patient Dental Yes No
l l l l – l l l – l l l l l
Name (Last, First, M)
Sex
M
F
Relationship
3
Dependent
Date of Birth
_______/_______/_______
Social Security Number
Address (if different from Employee)
Please check box when selecting HMO health plan coverage:
Permanently disabled and age 26 or older
4
Yes
No
Preferred Language
English Spanish Chinese Vietnamese
Korean Other
____________________________
Primary Care Physician
1
Name: _________________________________________________
Address: ___________________________________________________________________
ID#
Existing Patient Medical Yes No
Primary Care Dentist
2
Name: __________________________
ID#: ______________________________________________
Existing Patient Dental Yes No
l l l l – l l l – l l l l l
D. Other Medical Insurance/Health Plan Coverage Information
This section must be completed.
(Attach sheet if necessary.)
On the day this insurance/health plan coverage begins, will you, your spouse/domestic partner or any of your dependents be covered
under any other medical insurance/health plan coverage, including another UnitedHealthcare plan or Medicare?
YES (continue completing this section) NO (If NO, then skip the rest of the Other Medical Insurance/Health Plan Coverage section.)
Name of other carrier _____________________________________________________________________________________
Other Group Medical Insurance/Health Plan Coverage
Information (only list those covered by other plan)
Type
(B/S/F)
†
Effective Date
MM/DD/YY
End Date
MM/DD/YY
Name and date of birth of policyholder/covered
employee for other insurance/health plan coverage
Employee: / / / /
Spouse/Domestic Partner Name: / / / /
Dependent: / / / /
Dependent: / / / /
Dependent: / / / /
†
B. Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance/health plan coverage (married).
S. Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.
F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.
B. Dependent Information (continued)
D. Other Medical Insurance/Health Plan Coverage Information (continued)
SG.EE.16.CA 4/15
Subscriber Last, First Name _________________________________________ SSN ____________________________________
E. Waiver of Coverage
Complete only if you are waiving coverage for yourself and/or any family member.
I decline all coverage for:
Declining coverage reason:
Spouse’s Employer’s Plan Individual Plan COBRA/ Cal-COBRA AB1401
California Health Benet Exchange from Prior Employer
Covered by Medicare Medicaid Tri-Care
VA Eligibility I (we) have no other coverage at this time
Other _____________________________________________________________
Medical Dental Vision
Myself
Spouse/Domestic Partner
Dependent Children
Myself and all dependents
I acknowledge that the available coverages have been explained to me by my employer and I know that I have been given
the right and have been given the chance to apply for coverage. I have decided not to enroll myself and/or my dependent(s),
if any.
I now decline to enroll myself, my spouse/domestic partner and/or my dependent(s) in my employer health plan. I have made this
decision voluntarily, and no one has tried to inuence me or put any pressure on me to decline coverage. I ACKNOWLEDGE THAT
MY DEPENDENTS AND I MAY HAVE TO WAIT UP TO TWELVE (12) MONTHS TO BE ENROLLED IN THE GROUP MEDICAL
PLAN. THE WAIT OF UP TO TWELVE (12) MONTHS WILL NOT APPLY IF I AND/OR MY DEPENDENTS ARE ENTITLED
TO AN OFF-CYCLE ENROLLMENT PERIOD DUE TO CERTAIN CHANGED CIRCUMSTANCES (E.G., ACQUISITION OF A
DEPENDENT OR LOSS OF OTHER COVERAGE THROUGH A DEPENDENT.)
The wait of up to twelve (12) months will not apply if:
1. I certify at the time of initial enrollment that the coverage under another employer health benet plan, Healthy Families
Program, or no share-of-cost Medi-Cal coverage was the reason for declining enrollment, and I lose coverage under
that employer health benet plan, Healthy Families Program, Access for Infants and Mothers (AIM) Program, Covered
California, California’s Health Benet Exchange; or no share-of-cost Medi-Cal;
2. My employer offers multiple health benet plans and I elected a different plan during an open enrollment period;
3. A court orders that I provide coverage under this plan for a spouse or child;
4. I have a new dependent as a result of marriage, domestic partnership, birth, adoption or placement for adoption and if
enrollment is requested within 60 days after the marriage, domestic partnership, birth, adoption or placement for adoption;
5. I or my eligible dependents lose health care coverage due to a qualifying event such as loss of employment for any reason
other than gross misconduct, reduction of employment hours, death or entitlement to Medicare.
Employee Signature (only if waiving coverage for self and/or dependents) Date
_______________________
If you and/or an enrolling dependent are enrolled in Medicare, complete this section (attach additional sheets if necessary):
Medicare – Employee/Spouse/Domestic Partner/Dependent Name: ______________________________________________________
Medicare ID# _________________________________________________ (Please attach a copy of your Medicare ID card.)
Enrolled in Part A: Effective Date _____ /_____ /_____ Ineligible for Part A*
Enrolled in Part B: Effective Date _____/_____/______ Ineligible for Part B*
Enrolled in Part D: Effective Date _____/_____/______ Ineligible for Part D*
Not Enrolled in Part A (chose not to enroll)
Not Enrolled in Part B (chose not to enroll)
Not Enrolled in Part D (chose not to enroll)
Disabled Disabled but actively at work
Reason for Medicare eligibility: Over 65 Kidney Disease Disabled Disabled but actively at work
Are you receiving Social Security Disability Insurance (SSDI)? YES NO Start Date_____/_____/_____
*Only check “Ineligible” if you have received documentation from your Social Security benets that indicate that you are not eligible for Medicare.
If I am declining enrollment for myself and/or my dependent(s) (including my spouse/domestic partner) because of other
health insurance or group health plan coverage, I must request enrollment within 60 days after the other coverage ends (or
after the employer stops contributing toward the other coverage).
Please examine your options carefully before declining this coverage. (See Late Enrollment section of Evidence of Coverage
and Disclosure Form).
Subscriber Last, First Name _________________________________________ SSN ____________________________________
F. Application Signature
I understand that I am completing a health application and, to the best of my knowledge, that each response is complete and accurate. I
(we) request the indicated group medical coverage. I authorize any required premium contributions to be deducted from my earnings. I (we)
understand that UnitedHealthcare is not bound by any statements I (we) have made to any agent or to any other persons, if those statements
are not written or printed on this application and any attachments. Please maintain a copy of this authorization for your records.
Please note that if UnitedHealthcare can demonstrate you committed an act or practice that constituted fraud, or an intentional
misrepresentation of a material fact, UnitedHealthcare may rescind your coverage. UnitedHealthcare will issue a written notice via regular
certied 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. No agreement /policy will be rescinded after 24 months following the issuance of the agreement/policy. In addition, in the event it is
found you committed an act or practice that constituted fraud, or an intentional misrepresentation of a material fact, UnitedHealthcare may
cancel your coverage, as permitted by law.
Employee Signature (if applying for coverage) Employee Name (please print) Date
____________________
G. Census Information
NOTE: Data collected in this section will be used only to help communicate with enrollees and inform them of specic programs to
enhance their well-being. This information will not be used in the eligibility process.
1. Race, check all that apply: White Black, African-American Native Hawaiian/Pacic Islander Hispanic/Latino
American Indian/Alaska Native Asian Other Race, please specify _____________________
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.
PCA735117-000
SG.EE.16.CA 4/15
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FormWaiver of Coverage Small Business Employee Enrollment (Dickerson Insurance Services)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document