I hereby represent that I am an employee of the participating employer and that the statements and answers to the questions on this enrollment form are true and complete to the best of my knowledge and belief. I understand that the statements and answers contained herein will be used by Anderson Thornton Consultants to determine eligibility for group coverage under the PECAA Health Plan for myself and persons listed on this enrollment form as employees and their dependents.
I understand that (1) the answers given will be the basis of any coverage provided; (2) any material misrepresentation or failure to provide complete information to questions on this and/or subsequent form(s) may be used as a basis for changing rates or terminating coverage; (3) if coverage is not approved, I, my employees, nor their dependents are entitled to benefits; (4) coverage will not be effective until my employer receives notice that this enrollment form has been approved by the plan administrators.
I understand that this authorization is required in order to enable eligibility or enrollment determinations relating to me, my employees and/or their dependents or for administrators to make underwriting or risk rating determinations. If I refuse to sign this authorization, I may be refused coverage.