HomeMy WebLinkAboutUnited Healthcare Insured Employer ApplicationInsured Employer Application UnitedHealthcaxe'
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To avoid processing delays, please make sure you:
i. Answer all questions completely and accurately.
2. DO NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL
3. Include a deposit check in the amount of any required premiums; such amount will be returned in the event coverage does not become effective and will be
applied against the first month's premium if coverage does become effective.
Requested Effective Date 1 / 1 / 2 012
~ ~
Group's/Company's Legal Name
Orange County
Street Address Tax ID .
200 S. Cameron Street
St to Zip Code County
Ctty Hillsborough Forth Carolina 27278 Orange
Contact Person Telephone Fax Email Address
Diane Shepherd (919) 245-2558 (919) 644-3009 dshepherd@co.orange.nc.us
Billing Address (if different) ~ of Years in Business
Post Office Box 8181, Hillsborough, North Carolina 27278 259
Mufti-location group/company? ~ of Locations Address {es) (or list on additional sheet of paper}
I~Yes ONo Multiple All are located in Orange County
Organization Type ^ Partnership D C-Corp ^ S-Corp O LLC/LLP Nature of Business Industry Code
^ Ind. Contractor D Sole Proprietor ~] OtherGovernment Local Government 9131
Waiting Period ~J 1st of Policy Month following Date of Hire Waiting Period waived Medical Benefit EBISA Plan? .
for new hires D 1st of Policy Month #ollowing _ [months] [days) of employment Far initial enrollees Plan Option D Yes KJ No
D Date of Hire (no waiting period} D Yes ®No f~l Calendar Year
D ~ [months) [days} of employment following Date of Hire D Policy Year
D Other
Number of Persons currently on COBRAIContinua6on Number of Employees Termed Classes Excluded: ^ None O Union D Hourly
and/or Short/Long Tarm Disability in last 12 Months DNon-Management DNon-Owners
{employees/dependents) 9 O Temporary
Namo of Workers' Compensation Carrier Names of Owners/Partners not covered by Workers' Compensation
Sedgwick CMS N/A
C7 By checking this box, I acknowledge that I do NOT want UnitedHealthcare to act as my COBRA or state continuation of coverage administrator.
# Employees ~ Employees ~ Employer Employer
~ A in for. Waivin for: ~ °h % for De
P Eligible Employees Medical Modica{ Medical 10 0 52
t Ineligible Employees Dental Dental. Dental
Total i Employees Vision Vision Vision _. __ . ,; .^ : .
• :"=->=s
Basic EE life/AD&D Basic EE Life/AD&D Basic EE life/AO&D :=~r"w=~~i'- ~='`
Basic De Life Basic Dep Life Basic De Life
/ Hours per week 2 0 Su EE Life/AD&D Supp EE Life/AD&D Su EE Life/AD&D
to be eligible"" Su De lffe/AD&D Su De Life/AD&D Su De Life/AD&D
STD STD STD ';~~~`Y> "
"`~'
For Disability products the STD Bu U STD Buy U STD Bu U '=-~ -~:.¢-~
minimum i of work hours per
LTD
LTD -~~- £ ~x~ -~:~t
~=:'~ ~~ =~ ".~: -~:
week to be eligible is 30 hours. LTD ~ `
~•"~''~J
LTD Bu U
Y P LTD Buy Up LTD Buy Up ~: s"
'
Other Other Other
Coverage provided by "UnitedHealthcare and Affiliates":
Medical coverage provided by UnitedHealthcare Insurance Company [ar UnitedHealthcare of XXX}
Dental coverage provided by UnitedHealthcare Insurance Company [or UnitedHeslthcare of XXX1
Life, Short-Term Disability [STD) and Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance
Company
Vision coverage provided by UnitedHealthcare Insurance Company
page 1 of 4 Ixxx•xxxx alto]
tG.ER.ta.XX 6/10
^ Yes ~] No
O Yes 1'Cl Nc ,,, .,,o Nos~,v u,vmns, nos any creditor filed or threatened to file a petition requesting the Group/Company or any affiliated entity be
placed voluntarily into bankruptcy)
O Yes $7 No is your group a Professional Employer Organization (PEO) or Employee Leasing Company (ELC), or other such entity
that is a co-employer with your client(s) of client-site employee(s)?
If you answered Yes, then by signing this application you agree with the cerYrfication in this section.
hereby certify that my company is a PEO, ELC or other such entity and that only those employees that are the corparate employees of
my company, and not my co•employees, are permitted to enroll in this group policy. If my group at any point after l sign this application
determines that the group will provide coverage to the co-employees under the group's plan, I understand that UnitedHealthcare will
not cover the co-employees under this group policy.
What is your administrative policy regarding termination of eligibility for bane}Its related to your medical policy following a leave of absence?
(Please refer to the applicable state and federal rules that may require benefits to be provided for a specific length of time while an employee is on leave.)
^ Last Day worked (following the last day worked for the minimum hours required to be eligible}
^ 3 Months {following the last day worked for the minimum hours required to be eligible}
^ 6 Months (following the last day worked for the minimum hours required to be eligible}
^ UnitedHealthcare Policy Special Provisions Related to Medical Elfgibi(~ry*
~1 Qther(pleaseprovideacopyforaurrecords} (Last day o t e month after employee enters leave without pay status)
"UnltedHeafthcareSpacial Provisions Related to Medical Eligibility
If the employer continues to pay required medical premiums and continues participating under the medical policy, the covered person's coverage will remain
in force for: (1} No longer than 3 consecutive months if the employee is: temporarily laid•off; in part time status; or on an employer approved leave of absence.
(2} No longer than 6 consecutive months if the employee is totally disabled.
If this coverage terminates, the employee may exercise the rights under any applicable Continuation of Medical Coverage provision or the Conversion of
Medical Benefits provision described in the Certificate of Coverage.
do you currently otter or Intend to offer a Health Reimbursement Account {HRA} plan andler comprehensive supplemental insurance policy or funding
arrangement in addition to this UnitedHealthcare medical pfanT
Answers must be accurate whether purchased from UntedHealthcare orany other insurer or third party administrator.
HRA Yl Yes O No
if yos, please identify type: O UnitedHealthcare Definiry HRA (any HRA design offered through UnitedHealthcare) ^ Other Administrator HRA
HAA plans administered by other insurers or third perry administrators must complywith UnitedHealthcare HRA design standards.
Comprehensive Supplemental Insurance Policy or Funding Arrangement O Yes ^ No
If you answered °Yas' to either question above, you must choose from the list of UnitedHealthcare Definity HRA-eligible medical plans as shown to you by your
broker or agent. Other plans are not eligible for pairing with these arrangements. Purchase of such arrangements at any point during the duration of this
policy will require you to notify UnitedHealthcare.
nnn~ non nccvunr AammlStratOr:
Are there any other contributions or benefit reimbursements allowed? O Yes ;fc7 No
Who will provide account balances to UnitedHealthcare? n/a
In the past 36 months, has the Group/Company or any affiliated entity sled far protection or operated u der federal/state bankruptcy
Iaws7 (Chapter 7 or 11}
page 2 of
Does the group currently have any coverage with UnitedHealthcare orhas the group had any UnitedHealthcare coverage in the last 12 months?
DYes K7 No If Yes, please provide policy number and Coverage Begin Date^.I._/ End Date_.J_/
_~ 1... ... . d,...ee1 c n,innc rnr thw oravimis t2 ronsecutive months? ]Yes ^ NO
Name of C trier Coverage Begin Data Coverage End Daie
CurrentMedicslCarriar ^Nona County Commissioners (NCACC) Pre-2005 12/31/2011
Current Dental Carrier ^ None n/ a
Current Life Carrier ^ Nona n/a
Current Short•Term Disability Carrier ^ None n/a
Current Long-Term Disability Carrier ^ None n/ a
1 ~
It you are applying for medical coverage, please answer the following questions to the best of your knowledge by referencing available employee records and other
personnel documents for all eligible employees and dependents (proprietors, partners, corporate officers, employees, spouses, and dependent children) to the extent
permitted by applicable law. UnitedHealthcaro is antys~eking tocollect iniormationabout Ede current heath status of those employees and their dependentswho are
applying for coverage. in answering these questions, do not include any genetic information about your employees or their dependents, including requests for genetic
services, genetic diseases for which they may be at risk or family medical history information.
Please provide details to "Yas" answers in the space provided.
IMPDRTANT: Your answers to these questions must include all COBRA and State Continued individuals covered by your present plan.
^ Yes D No 1. Within the past 3 years, has any employee or dependent filed a claim for short-term disability, long term disability, social security
disability income, workers' compensation, Medicare, or Medicaid benefits or any other type of disability benefits on any policy?
DYes ^ No 2. During the past 3 years, has any employee or dependent had life, disability or health insurance declined, postponed, changed,
cancelled or withdrawn?
^ Yes ^ No 3. Except far a maternity or paternity leave, within the past 3 years, has any employee applied for a family or medical leave of more than
2 weeks due to injury, disability or illness of the employee or dependent?
O Yes ^ No 4. Within the past 3 years, has any employee been absent from work for more than 2 consecutive weeks due to injury, disability or illness?
~] Yes D No 5. Except for a mental health admission, during the past 3 years, has any employee or dependent had a hospital stay lasting more than
5 days or is any employee or dependent contemplating treatment that would require hospitalization for more than 5 days?
DYes ^ No ti. Is any employee or dependent currently hoe 't~lized? ~ , '1, •
DYes ^ No 7. Within the past 3 years has any emplo e a ~ endent beet~iagnosed, treated for, or cat ed, r_~@@scri lion medication for one of the
following conditions? (refer C Rep s previo~us~Lw-~.~ett) p
D Cancer (env type} ^ Hepatitis ~'""
^ Lung disease or respiratory problem (any type)
^ Heart disease or disorder (any type)
^ Organ, tissue or cell transplant
^ Liver disease {any type)
^ Kidneydisease{anytype)
^ Pancreatic disorder {any type)
^ Diabetes
^ Morbid obesity
^ Congenital abnormality
^ Vascular disease (any type)
^ Neurological disorder (any type)
O lmmunoiogical disorder (reportable types)
^ Alcohol or drug addiction or abuse
. ...,._ .~___, ,e _______-..._.....rd:,:..ml eMeeee er nonor
If you hav
Question
Number e answered
Che
Employee
REFE "Yas" to a
One
De endent
TO NC ny of t
Age
CC he question
Date of
fiecave
REPOR s above, lease rovtua
Date of Treatment/
Candhion
S PREVIOUSLY the re uesteu rmormau
Nature of
Medication
ROVIDED un rot ~~~~~ ~~~"~.~"~a,
Name of
Condition • ~~ ~~o~o~"
$ Amount
of Claims •,. ""- ---•••-••-• _..__._ _. _ _..
Current
Treauent
page 3 of 4
The Group/Company certifies that the information provided above is complete and accurate. The Group/Company shall notify UnitedHealthcare and Affiliates
promptly of any changes in this information that may affect the eligibility of employees or their dependents, including the addition of any newly eligible
employees or dependents. Prior to receiving notification of approval, the Group/Company shall notify UnitedHealthcare and Affiliates promptly of any significant
changes in the health status of an eligible employee or dependent including any inpatient hospital admissions. UnitedHealthcare and Affiliates shall tie entitled
to rely on the most current information in its possession regarding the eligibility and health status of employees and their dependents in providing coverage
under the policy/policies for which application is being made.
I represent to the best of my knowledge the information I have furnished is accurate, and includes any employees and dependents who have elected
continuation of insurance benefits. I understand that malarial omissions misrepresentations or misstatements in the information requested on this form can
result in the adjustment of rating or voiding of insurance.
i understand thstthe Certificate of Coverage or Summary Plan Description and other documents, notices and communications regarding the benefit plans}
indicated herein on this Application may be transmitted electronically to me and to the Group's/Company's employees.
Any person who knowingly and with intent to defraud any insurance company ar other person tales an application for insurance containing any materially false
information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Upon receipt by UnitedHealthcare and Affiliates of this signed employer application and payment of the required policy charges, the group policy is deemed
executed. The deposit check in the estimated amount of the first month's premium is not considered payment of the required policy charges.
UnitedHealthcare disclosure regarding producer compensation:
'We pay brokers and agents (referred to collectively as'producers"}compensation for their services in connection with the sate of our insured products, in
compliance with applicable law. We pay "base commissions' based on factors such as product type, amount of premium, group/company size and number of
employees. These commissions are reflected in the premium rate. In addition, wa may pay bonuses pursuant to bonus programs established from time to
time which are designed to encourage the introduction of new products and provide incentives to achieve production targets, persistency levels, growth goals
or other objectives. Bonus expenses are not directly reflected in the premium rate but era included as part of the general administrative expenses. It is our
policy not to pay commissions to producers with respect to a product for which the customer is also paying the producer a commission or other fee. Please
note we also make payments from time to time to producers for services other than those relating to the sale of policies (for example, compensation for
services as a genera! agent or as a consultant).
Producer compensation is subject to disclosure on Schedule A of the ER1SA Form 5500 for customers governed by ERISA. We provide Schedule A reports to
our customers as required by applicable federal law. We also have taken steps to ensure that producers property disclose their compensation arrangements
to their customers, but we cannot guarantee the producer's compliance. Far general information on our producer payment arrangements, including the
approximate percentage of total compensation that total bonus payments comprise, please go to httpJ/www.uhc.com and click on the drop down box for
employers under'~ew Our Programs -Producer Payment Programs.' For specific information about the compensation payable with respect to your
particular policy, please contact your producer. ~
Group/Company Signatur r' ~ Z ~ ~ ~ ~~ f~I
D rue
THIS DOCUMENT E p
DO NOT CEt YO V THE ~>°~~ T~~~'~g~~~ ~ ~,
FISCAL CONTROL ACT. Clarenee G. Grier, Financial Services Director
~~ ~ e
Broker Name Agency
Agent Code/Tax ID Number
Signature Email Address SocialSecurity# PhaneNumber Oate
Rep Name
Rep #
Commissions payable to
Broker Commission Schedule Std Scale of %
page 4 of 4