/depts/,/depts/uwhealth/,/depts/uwhealth/benefits/,/depts/uwhealth/benefits/open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/health-insurance/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/health-insurance/resources/,

/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/health-insurance/resources/Quartz-Application-OE.pdf

201710296

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UWHC,UWMF,

Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWMF Open Enrollment,Health Insurance,Resources

Open Enrollment Health Insurance Enrollment Form

Open Enrollment Health Insurance Enrollment Form - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWMF Open Enrollment, Health Insurance, Resources


Employee Application
Please Complete Entire Form in BLACK INK
Underwritten by
Unity Health Plans Insurance Corporation
840 Carolina Street • Sauk City, WI 53583-1374
(800) 362-3309 • Fax (608) 643-2564
QuartzBenefits.com
UH00314 (rev 08 17)
II. EMPLOYER Please Complete This Section
Requested Effective Date of Coverage:
______/_____/______
Employment Status: � Active � Retired � LOA
� COBRA / Continuation Effective Date ______/_____/______
Reason: � End of Employment � Death of Employee � Entitlement to Medicare
� Reduction in Hours of Employment � Divorce or Legal Separation � Loss of Dependent Child Status
Name of Employer Group:
City, State, Zip:
Employer Contact: Contact Email:
Date Employed: ______/_____/______ Hours Employee Works Per Week:
Applicant’s Last Name First Name MI Primary Language � English � Spanish
� Other:____________________________
Mailing Address City State Zip Code County Height / Weight
Street Address (if different from Mailing Address) Apt. City State Zip Code County
Social Security Number or Tax ID Number: (SSN / TIN is required for IRS tax reporting regarding your health plan.)
Email:
Date of Birth Gender Marital Status
Home Phone Number (__________)_______________________________
� M � Single � Married � Divorced
Work Phone Number (__________)________________________________
� F � Separated � Widowed
Cell Phone Number (__________)__________________________________
Plan: � Traditional HMO _______________________ HMO HDHP______________________
Type of Coverage: � Employee � Employee and Spouse � Employee and Child(ren � Family
� WAIVING COVERAGE (skip to section V. Waiver of Group Coverage)
Current Patient

Yes

No
I. Employee Information (Please do not use abbreviations or nicknames on this application)
III. Dependent Information – In addition to the Employee, listed above, please list all other persons applying for coverage.
Dependent Name Social Security or Tax ID Number Relationship Date of Birth Gender Height *Clinic and PCP or NP Name Current Patient?
(Last, First, MI) and Weight
� M � F � Yes � No
� M � F � Yes � No
� M � F � Yes � No
� M � F � Yes � No
� M � F � Yes � No
_____/____/_____
Confirm your NP can be selected as a
PCP at QuartzBenefits.com/findadoctor.
If no PCP or NP preference,
indicate “ASSIGN”.
(SSN / TIN is required for IRS tax
reporting regarding your health plan.)
*Primary Care Physician (PCP)or Nurse Practitioner (NP) and Clinic
**EMPLOYEE MUST COMPLETE THIS SECTION**
OPEN ENROLLMENT 2018
**Quartz Will Assign**
**Quartz Will Assign**
**Quartz Will Assign**
**Quartz Will Assign**
**Quartz Will Assign**
**Quartz Will Assign**
01 01 2018 This application is being submitted for Open Enrollment
Employee ID: ________
Submit applications to Human Resources by October 27 deadline:
Ask HR case in ServiceNow | Fax: 608-263-5778

Note: If you are waiving your right to this group coverage, you do not need to complete the General Information and Medical Information.
IV. General Information and Medical Information
1. Have you or any dependent ever been insured by Quartz? � Yes � No
If yes, give subscriber name__________________________________________ Dates previously covered by Quartz ______________________________
2. Will you or any of your dependents continue to have other insurance after the Quartz effective date of this policy? � Yes � No
If Yes, complete the following information:
Name(s) of Insured ________________________________________________________ Employer_____________________________________________
Insurance Company _______________________________________________________ Insurance Company Phone # ___________________________
Subscriber # _____________________________________________________________ Group # _____________________________________________
Address______________________________________________________________________________ Effective Date of Coverage _________________
3. Are you or any family member(s) enrolled in Medicare? � Yes � No
If yes, please answer the following and attach a copy of your Medicare Card.
Name _________________________________________________________ Name_________________________________________________________
Medicare #_____________________________________________________ Medicare #_____________________________________________________
Effective Date, Part A ____________________________________________ Effective Date, Part A ___________________________________________
Effective Date, Part B ____________________________________________ Effective Date, Part B____________________________________________
Effective Date, Part C (Medicare Advantage) ____________________________ Effective Date, Part C (Medicare Advantage) ____________________________
Effective Date, Part D_____________________________________________ Effective Date, Part D____________________________________________
Reason for Medicare: � Age 65 � Disability � End Stage Renal Disease � Disability and ESRD
4. Are you or any dependent now disabled or unable to perform normal activities? � Yes � No
If yes, Name of person _______________________________________ Type of disability ________________________ Date of disability_______________
5. Have you or any dependent incurred health claims in excess of $5,000 during the last 24 months? � Yes � No
If yes, Name of person _______________________________________ Reason_____________________________________________________________
6. Within the last 24 months have you or any dependent listed above consulted about, received treatment for or been diagnosed with: cancer, stroke,
diabetes, heart condition (including hypertension), vascular disease, behavioral health (mental, anxiety or emotional disorder), muscular or systemic
disease (such as arthritis or lupus), alcohol or drug use, liver, kidney, lung (such as COPD or asthma) or intestinal disorder? � Yes � No
If yes, please explain on a separate sheet of paper and attach to this form. (You do not need to report genetic tests or test results.)
7. Have you ever been diagnosed by a member of the medical profession as having an immune system disorder, AIDS or ARC? � Yes � No
(You do not need to report HIV test results.)
8. Are you or any dependents currently taking any medications? � Yes � No
If yes, please list the medications: __________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
9. Are you or is any dependent listed above pregnant? Have you or has any listed dependent scheduled or had any surgeries in the last 12 months?
Have you or has any listed dependent been hospitalized in the last 12 months? � Yes � No
If Yes, Name(s) ____________________________________________________________________________ Pregnancy Due Date___________________
Reason for hospitalization or surgery:_______________________________________________________________________________________________
10. Are you or any dependents listed above involved in a Workers Compensation case? � Yes � No
If Yes, indicate family member involved and start date / accident date:____________________________________________________________________
Workers Compensation Condition:_________________________________________________________________________________________________
Insurance Co Name: _____________________________________________________________________________________________________________
Insurance Co Address: (where claim is sent) ____________________________________________________________________________________________
Insurance Co Phone:_____________________________________________________________________________________________________________
Group#: _______________________________________________________________________________________________________________________
Effective Date:______________________________________________ Term Date (if applicable):______________________________________________
UH00314 (rev 08 17)

I acknowledge that I have read and completed the entire Application. If I received assistance in reading or completing this Application, I have identified
the person(s) who assisted me.
I agree that the answers are, to the best of my knowledge and ability, complete and true. I understand that my answers, together with any supplements or
additional pages, are the basis for the certificate or policy that is issued. I agree that no insurance will be effective until the date specified by the
insurance company on the certificate or policy. I understand that any material misstatement or omission relied upon by the insurer may result in denial of
claim and / or rescission of coverage. I further understand that this contract can be voided if within the first 24 months from the date of the policy or
certificate it is determined that I or a dependent made an intentional misrepresentation in the application.
I understand that it may be a crime to submit an application or file a claim based on a false or deceptive statement. I further understand it may be a crime
to submit an application that is intended to mislead an insurer or conceal significant information about the applicant.
I understand that I may request a copy of this Application and the notice of the company’s privacy practices. I agree that a photocopy is as valid as an
original. A legible facsimile or electronic signature shall have the same force as the original. I agree that Quartz may use the email addresses provided in
this document to contact the individuals listed in this document.
I understand that enrollment and / or eligibility for benefits may be conditioned upon my willingness to provide written authorization permitting Quartz to
obtain medical records from health care providers who have treated me, my spouse or any dependents applying for coverage under this application. If
medical records are needed, Quartz will provide me with an authorization form.
Applicant’s Signature: ___________________________________________________________________________ Date______________________________
Notice of Special Enrollment Rights
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage,
you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer
stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 31 days after your or your
dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your
dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
UH00314 (rev 08 17)
I hereby elect not to apply for group health plan coverage. I hereby waive group health plan coverage for:
� Myself � Spouse � Children or other eligible dependents
Reason for waiving coverage –
� I / we will be covered under another health benefit plan that is not sponsored by my employer.
Name of Insurance Co.: __________________________________________________________________________________________________
� I would have to pay more than 10 percent of my annualized gross income towards health insurance
� Other reason for waiving:_________________________________________________________________________________________________
I certify that I have been given the opportunity to apply for the Quartz group health benefit plan coverage for which I am eligible. I decline to enroll
for such coverage as indicated above, on behalf of the persons listed above. I understand that I may be able to obtain coverage at a later time for
reasons listed in the Notice of Special Enrollment Rights. If circumstances in the Notice of Special Enrollment Rights do not apply then me and/or
the persons listed above may be considered Late Applicants subject to either a 12 month delayed effective date, or, if my employer has an Open
Enrollment Period, may be able to apply for coverage at Open Enrollment.
I certify that the information above is, to the best of my knowledge and ability, complete and true.
Applicant’s Signature: _____________________________________________________________________________ Date______________________________
V. Waiver of Group Coverage: