A - EMPLOYEE (Primary Applicant)
EMPLOYER INFORMATION (must be completed)
Company Name
*
Company Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
BENEFIT PLAN:
GROUP NUMBER:
Name
*
First Name
Middle Initial
Last Name
Social Security Number (do not add dashes):
*
Birthdate
*
/
Month
/
Day
Year
Date
Gender
*
M
F
Average number of hours worked per week?
*
Date employed Full-Time: (mm/dd/yyyy)
*
/
Month
/
Day
Year
Date
Home Address
*
Home Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip
Mailing Address (if different)
Home Street Address
Street Address Line 2
City
State
Zip
Cell Phone Number
*
-
Area Code
Phone Number
Home Phone Number
-
Area Code
Phone Number
Work Phone Number
-
Area Code
Phone Number
Email Address:
*
example@example.com
Best Time to Call:
*
Job Title
*
Employee Status:
*
W2
1099
Owner/Partner
Marital Status
*
Single
Married
Check one:
*
Full Time
Part Time
Retiree
COBRA
Cal-Cobra
COBRA Effective Date
/
Month
/
Day
Year
Date
Earnings Basis
*
Salaried
Hourly
Commission only
NEW ENROLLMENT or WAIVER, please check one:
*
New Hire
Re-hire
Open Enrollment
New Group
Qualifying Life Event:
COBRA
Waiver of Coverage
Other
Qualifying Life Event:
Qualifying Life Event Date: (mm/dd/yyyy)
/
Month
/
Day
Year
Date
Indicate the waiver reason below.
*
Individual Medical
Medicare/Medicaid
COBRA/Continuation
Tricare
Spouse’s Employer
Cost/Do not want
Other
Signature
Date
*
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date employed Full-Time:
*
/
Month
/
Day
Year
Date
Back
Next
C – ONLY TO BE COMPLETED BY ADDITIONS TO EXISTING GROUPS OR FOR CHANGES TO EXISTING COVERAGE
Are you enrolling outside of employers open enrollment period? (special election period)
*
Yes
No
Requested effective date: (must be 1st or 15th, subject to underwriting approval)
*
/
Month
/
Day
Year
Date
Groups with multiple medical plans, indicate which plan you are requesting:
If dental coverage offered, are you electing?
*
Yes
No
If yes, list those enrolling
If multiple dental plans are offered, which plan are you requesting? * Dental Plan
If vision coverage offered, are you electing?
*
Yes
No
If yes, list those enrolling
4.If enrolling outside of your employer’s open enrollment period, indicate the special enrollment reason (documentation may be required)
*
Marriage
Birth
Adoption
Court ordered (copy of court order required)
Divorce/Separation
Involuntary loss of coverage
COBRA/Continuation exhausted
Other
For any event above, list date of event
/
Month
/
Day
Year
Date
State Reason for Loss
For any event above, list coverage termination date
/
Month
/
Day
Year
Date
D – PERSONS TO BE COVERED
(Include yourself and all family members to be insured. If more space is needed, proceed to spreadsheet)
*
Employee Only
Employee and Spouse
Employee and Child(ren)
Family: Employee, Spouse, & Child(ren)
Name
First Name
Last Name
Gender
M
F
Spouse's Name
First Name
Last Name
Spouse
M
F
Spouse Birthdate
-
Month
-
Day
Year
Date
Spouse SS#
Child #1's Name
First Name
Last Name
Child #1
M
F
Child 1 Birthdate
/
Month
/
Day
Year
Date
Child #1 SS#
Child #2's Name
First Name
Last Name
Child #2
M
F
Child #2 Birthdate
/
Month
/
Day
Year
Date
Child #2 SS#
Child #3's Name
First Name
Last Name
Child #3
M
F
Child #3 Birthdate
/
Month
/
Day
Year
Date
Child #3 SS#
Child #4's Name
First Name
Last Name
Child #4
M
F
Child #4 Birthdate
/
Month
/
Day
Year
Date
Child #4 SS#
Child #5's Name
First Name
Last Name
Child #5
M
F
Child #5 Birthdate
/
Month
/
Day
Year
Date
Child #5 SS#
E – ADDITIONAL INSURANCE COVERAGE INFORMATION
1. Will any current medical plan remain active if coverage is approved?
*
Yes
No
If “Yes”, for whom?
Please provide carrier and ID/Group number
2. Are you, your spouse or any dependent children currently covered under Medicare Part A, B, or D?
*
Yes
No
If “Yes”, for whom?
If “Yes”, will coverage remain active if the coverage for which you are applying is approved?
Yes
No
Employee Height (in feet)
*
Employee Height (in Inches)
*
Employee Weight (in pounds)
*
Employee used any form of tobacco/nicotine in the last 12 months?
*
Yes
No
Spouse Height (in feet)
*
Spouse Height (in inches)
*
Spouse Weight (in pounds)
*
Spouse used any form of tobacco/nicotine in the last 12 months?
Yes
No
Select all that apply
*
AIDS or HIV
Alcohol or Drug Use, or Dependency
Arthritis or other Skeletal Disorder
~ Osteoarthritis
~ Rheumatoid
~ Other - arthritis or skeletal disorder
Back Disorders
~ Chiro
~ Sprain/Strain
~ Surgery
~ Other - back disorders
Blood Disorders (including anemia)
Cancer or Tumor
~ Local (confined to the organ where it began)
~ Regional (spread to nearby lymph nodes/organs)
~ Distant/Metastasis (spread to distant organs)
Chest Pain
Diabetes Mellitus
~ Pre-Diabetes
~ Diet Controlled
~ Type I
~ Type II
~ Insulin Dependent
~ Insulin Pump
Diabetic Related Disorders
~ Heart disease
~ Nephropathy
~ Neuropathy
~ Peripheral Vascular Disease
~ Retinopathy
~ Stroke
Digestive Disorder
~ Crohn’s Disease
~ Ulcerative Colitis
~ Other - digestive disorder
Ear/Eye/Nose/Throat Disorders
Endocrine Disorders
Fracture/Broken Bone
Heart Disorders
~ Angioplasty
~ Bypass
~ Heart Attack
~ Other - heart disorder
High Cholesterol
High Blood Pressure
Hodgkin’s/Lymphoma/Leukemia
Immune Disorders
Infertility
Kidney Disorders
Knee Injury or Disorder
Liver Disorder/Hepatitis
~ Hepatitis B
~ Hepatitis C
~ Hepatitis D
~ Other - liver disorder/hepatitus
Lupus
~ Discoid
~ Systemic Lupus Erythematosus
Mental, Nervous or Behavioral Disorder
~ Inpatient Treatment
~ Outpatient Treatment
~ ADHD/ADD
~ Anxiety
~ Bipolar disorder
~ Depression
~ Other - mental, nervous or behavioral
Migraine or Chronic Headache
Multiple Sclerosis (MS)
Muscle Disorders
Nervous System Disorders
~ Paralysis
~ Partial or Total Disability
Physical Disorder or Deformity
Reproductive Disorders
Respiratory/Lung Disorders
~ Asthma
~ Chronic Bronchitis
~ COPD
~ Other - respiratory/lung disorders
Seizures
Sexually Transmitted Disease
Stroke or Transient Ischemic Attack
Thyroid Disorder
~ Hyperthyroidism
~ Hypothyroidism
~ Growth Disorder
~ Other - thyroid disorder
Transplant
~ Solid Organ
~ Blood or Marrow
Urinary Disorders
Vascular Disorders
None of the above apply
Please provide FULL DETAILS to any yes/checked answers in section F; including the name of the Applicant(s), condition(s), treatment(s), medication(s), and dates. If more space is needed please attach a separate page with details; include the Employee’s name. (if none, please enter N/A in first row)
Person
Condition/Diagnosis
Dates Treated
Treatment including Medications and Dosage
Date Last Taken
Prognosis
1
2
3
4
5
6
7
8
Please provide FULL DETAILS to any yes/checked answers in section F; including the name of the Applicant(s), condition(s), treatment(s), medication(s), and dates. If more space is needed please attach a separate page with details; include the Employee’s name. (if none, please enter N/A in first row)
*
Person
Condition/Diagnosis
Dates Treated
Treatments including
Medications and Dosage
Date Last Taken
Prognosis
1
2
3
4
5
6
7
8
Diabetes Mellitus Date of Onset
/
Month
/
Day
Year
Date
Cancer Stage (If Applicable)
Have you answered yes to any of the above conditions?
*
Yes
No
Please list any/all primary physicians or facilities that you currently see for medical services. This will allow EHBA to reach out proactively to introduce Exemplar Health and give them information on how your plan is designed. (If you have none, please enter N/A)
*
In the last 5 years, have you or any of your dependents included on this enrollment form been diagnosed with or treated for any condition(s) not identified above?
*
Yes
No
In the last 5 years, have you or any of your dependents included on this enrollment form been advised of the necessity or possibility of any future hospitalization, treatment, testing or surgery??
*
Yes
No
4. Are you or any of your dependents included on this enrollment form currently pregnant?
*
Yes
No
If yes, Indicate due date
/
Month
/
Day
Year
Date
Is a Cesarean Section anticipated?
Yes
No
Are multiple births expected?
Yes
No
Are you/your dependent experiencing or anticipating any other complications?
Yes
No
Have medications been prescribed in the past 18 months for you and/or any dependents included on this enrollment form.(Include pills, creams, injections, liquids, inhalers, pumps, etc.
*
Yes
No
G – DETAILS
Signature
*
Date
*
-
Month
-
Day
Year
Date
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