Fill - Free fillable United Healthcare - Form 932E Application for Short Term Medical Insurance PDF form

STM-AP-160-GRI-24R 932E-G-1116

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*%9932E-G-1116*

MISSOURI

APPLICATION FOR SHORT TERM MEDICAL INSURANCE

GOLDEN RULE INSURANCE COMPANY — INDIANAPOLIS, INDIANA 46278-1719

Please Print

in Black Ink

( )

PROPOSED INSURED

/ /

First Middle Initial Last Height Weight Birth Date Age

Resident Physical Address (where you live and pay taxes).

PO Boxes are not accepted.

Street (Include Apt.) City State ZIP Telephone No.

Mailing Address

(if different than Resident Address)

_________________________________________________________________________________________________________________

Street (Include Apt.) City State ZIP

Email Address _____________________________________________________________________________________________________

Proposed Insured Spouse (if to be covered)

1. List below any dependents to be covered under the policy.

Male

Female

*If born within 30 days prior to the effective date of coverage, the person will not be covered under the policy.

2. Are you or is any family member (whether or not named in this application) an expectant mother or father, in the process of Yes No

adopting a child, or undergoing infertility treatment?......................................................................................................................

If yes, coverage cannot be issued.

3. Have you or has any person named in Question 1 lived in the 50 states of the USA or the District of Columbia for less than

the past 12 months? If yes, state the name of each person: ____________________________________________________

(The person(s) named will not be covered under the policy.)

4. Do you or does any person named in Question 1 now have hospital or medical expense insurance that will not terminate ........

prior to the requested effective date? If yes, state the name of each person: _______________________________________

(The person(s) named will not be covered under the policy.)

Within the last 5 years, have you or has anyone listed on the application received medical or surgical consultation, advice, or

treatment, including medication, for any of the following: blood disorders, liver disorders, kidney disorders, chronic obstructive

pulmonary disorder (COPD) or emphysema, diabetes, cancer, heart or circulatory system disorders (excluding high blood

pressure), Crohn's disease or ulcerative colitis, or alcohol or drug abuse or immune system disorders?

........................................

If yes, state the name of each person: _____________________________________________________________________

(The person(s) named will not be covered under the policy.)

6. Within the last 5 years, have you or has anyone listed on the application received diagnosis or treatment for HIV infection

from a doctor or other licensed clinical professional, or had a positive test for HIV infection performed by a doctor or

other licensed clinical professional? ...............................................................................................................................................

If yes, state the name of each person: _____________________________________________________________________

(The person(s) named will not be covered under the policy.)

7. Have you or has any person named in Question 1 had testing performed and has not received results, or been advised by a

medical professional to have treatment, testing, or surgery that has not been performed? ...........................................................

If yes, state the name of each person: _____________________________________________________________________

(The person(s) named will not be covered under the policy.)

Dependent’s Name (Last, First, M.I.) Relationship Height Weight Date of Birth

Spouse / /

/ /

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STATEMENT OF UNDERSTANDING

I have read this application and represent that the information shown on it is true and complete. I understand that: (a) no insurance will become effective

unless my application is approved and the appropriate premium is actually received by Golden Rule with this application; (b) no benets will be paid for a health

condition that exists prior to the date insurance takes effect; and (c) if coverage is issued, the coverage will not be a continuation of any prior coverage.

Incorrect or incomplete information on this application may result in voidance of coverage and claim denial. The information provided in this application, and any

supplement or amendments to it, will be made a part of any policy that may be issued. I understand that for an application sent by any electronic means,

insurance, if approved, will be effective the later of: (i) the requested effective date; or (ii) the day after receipt by Golden Rule. I understand that for a mailed

application, insurance, if approved, will be effective the later of: (i) the requested effective date; or (ii) the day after the postmark date affixed by the U.S. Postal

Service. If mailed and not postmarked by the U.S. Postal Service or if the postmark is not legible, the effective date will be the later of: (i) the requested effective

date; or (ii) the date received by Golden Rule. I understand that the broker is only authorized to submit the application and initial premium and may not change

or waive any right or requirement.

_____________________________________________________________________________ __________________________

Proposed Insured’s Signature or Parent/Legal Guardian if proposed insured is a child Date you signed and read application

___________________________________________ ________________________________ __________________________

Spouse (if to be covered) Licensed Agent or Broker (Please Print) Individual Producer #

Important Notes:

• “Postmark date” means the date of the postmark as affixed by the U.S. Postal Service.

• No application will be accepted if received by Golden Rule more than 15 days after the date signed.

• Altered applications will not be accepted.

Short Term Medical Plus Elite Short Term Medical Copay Short Term Medical Copay Value

80/20 - $2,000

70/30 - $5,000

Short Term Medical Plus Short Term Medical Value

80/20 - $2,000 70/30 - $5,000

70/30 - $5,000 70/30 - $10,000

DEDUCTIBLE: $1,000 $1,500 $2,500 $5,000 $10,000

MONTHS OF COVERAGE: 1 2 3 4 5 6

OPTIONAL BENEFITS:

Supplemental Accident Benet

$1,000

$1,500

$2,500

$5,000

$10,000

Per Cause Deductible

PRESCRIPTION DRUGS - Select one option:

Prescription Drug - 4 Tier (Available with Short Term Medical Copay Plan only)

Prescription Drug - Discount Card Only (Available with Short Term Medical Copay Plan only)

Prescription Drug - Add Coverage (Available with Short Term Medical Copay Value Plan only)

Prescription Drug - Generic $20 Copay (Available with all Plans except Short Term Medical Value)

REQUESTED

EFFECTIVE DATE:

______/______/_______

(See Statement of Understanding

section.)

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PAYMENT OPTIONS: SINGLE OR MONTHLY (Initial Payment Method Required With Application)

Electronic Funds Transfer (EFT) and Credit Card payment will be collected on the date we issue coverage, or the effective date of the policy, whichever is later.

If coverage is not issued, we will collect EFT or Credit Card payment for the nonrefundable application fee on the date of our decision.

Payor: ____________________________________________________________________________________________________________________

Name Email Address

__________________________________________________________________________________________________________________________

Street City State ZIP

____________________________________________

Contact Number

PAYOR INFORMATION (If other than Proposed Insured)

( )

CREDIT CARD AUTHORIZATION — COMPLETE ONLY IF PAYING BY CREDIT CARD

Credit Card Authorization Visa MasterCard American Express

I authorize Golden Rule Insurance Company to charge my Visa/MasterCard/American Express account for the Single Payment or Monthly Payment above.

_____/______/______ X ___________________________________

Account No. Expiration Date Billing ZIP Code Signature of Authorized User

NOTE: Some card issuers/financial institutions charge cash advance fees on insurance payments. Charge On __________________

(29th, 30th, 31st not available)

Day

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION — COMPLETE ONLY IF PAYING BY EFT

I (we) hereby authorize Golden Rule to initiate

debit entries to the account indicated below.

I also authorize the named financial institution

to debit the same to such account.

I agree this authorization will remain in effect

until you actually receive written notification of

its termination from me.

Type of Account: Checking Savings

Nine-digit Routing No.

Account No.

Financial Institution’s Name _____________________________________

Address _____________________________________________________

City, State, ZIP ________________________________________________

Draft On _________________________ ________________________

Day Date Signed

X __________________________________________________________

Authorized Account Signature

In Tennessee and Texas, drafts may only be scheduled on 1) the premium

due date; or 2) up to 10 days after the due date.

/ /

Single Payment (one single payment for all months of coverage chosen):

EFT $ Amount ___________ Includes $20 nonrefundable application fee.

Please complete the EFT Authorization below.

Credit card $ Amount ___________ Includes $20 nonrefundable application fee.

Please complete the Credit Card Authorization below.

Check or money order $ Amount ___________ Includes $20 nonrefundable application fee.

Please mail your check or money order, payable to Golden Rule Insurance Company, with your application. Checks are deposited upon receipt.

OR ————————————————————————————————————————————————————————

Monthly Payment:

Initial Payment EFT (Ongoing payment must be EFT.) Credit Card Check or money order

Please mail your check or money order, payable to Golden Rule Insurance Company, with your application. Checks are deposited upon receipt.

$ Amount ___________ Initial Payment amount (shown) includes a one-time $20 nonrefundable application fee.

Ongoing Payments (Choose one)

Direct Bill ($10 monthly billing fee.)

Ongoing monthly Direct Bill payments will not include the $20 application fee, however they will include a $10 monthly billing fee.

Electronic Funds Transfer (EFT) (No billing fee.)

Ongoing monthly EFT payments will not include the $20 application fee.

Credit Card (No billing fee.)

Ongoing monthly Credit Card payments will not include the $20 application fee.

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44177a-X-1115

CONSENT TO RECEIVE ELECTRONIC RECORDS

AND TO CONDUCT TRANSACTIONS ELECTRONICALLY

By submitting this consent form or a health insurance application or HMO enrollment form, you hereby consent

to presentation, delivery, storage retrieval and transmission of “Communications” related to “Our Transaction” as

electronic records instead of in paper form.

For the purposes of this form, “Our Transaction” means the entirety of the business relationship between you and

us. “Communications” includes, but is not limited to:

1. Your application or enrollment form, including subsequent amendments;

2. Information related to Our Transaction that we are required to provide or make available in writing such as

privacy notices or fraud warnings;

3. Documents related to Our Transaction such as policy, certicate, or evidence of coverage forms, claim

forms, explanation of benet forms, premium notices, or other administrative forms (to the extent permitted

by applicable law);

4. Any emails, faxes, recorded telephone calls, or other electronic transmissions of information between you

and us and an insurance producer contracted with us, or between us and any third party.

Subject to our obligations to protect your privacy, we may, at our sole discretion, post Communications on a

website (in which case they will be sent or received, as the case may be, regardless of whether or not we own,

operate or control the website). Or send them in or attached to an email. You must promptly tell us about any

change to your electronic or physical mailing address, or other contact information.

You acknowledge that you can receive or access Communications because you have the following:

• A telephone

• A computer and printer

• A device or computer program for listening to audio CDs, mp3, WAV or other common computer audio les

• An Internet browser

• Access to the Internet

• A valid email address

• Adobe Acrobat Reader or other sufficient PDF reader

You can request a free copy of any Communications, or withdraw your consent to receive electronic

Communications at any time by sending a written request to:

Policy Administration

PO Box 31372

Salt Lake City, UT 84131-0372

I hereby consent to receive Communications and Transaction Documents electronically, as per the

aforementioned conditions. All of the Communications between the time you submit your consent and

withdraw your consent will remain valid and binding on both you and us notwithstanding your withdrawal.

I hereby DO NOT consent to receive Communications and Transaction Documents electronically,

as per the aforementioned conditions. If you do not consent, we will conduct all future business with you

in paper form.

X _____________________________________________ X _____________________________________________

Primary Applicant (You) Parent/Guardian (if you are a minor) Relationship

_____________________________________________ X _____________________________________________

Primary Applicant (You) Email Address Parent/Guardian (if you are a minor) Email Address

_____________________________________________

Date

Aug 25 2016 02:30:46 pm

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United Healthcare - Form 932E Application for Short Term Medical Insurance

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