1. health and fitness

How to request a change in your ISMA
sponsored Anthem health insurance policy
To request a change in your ISMA health insurance policy, complete the sections of an Anthem
Enrollment form indicated in the chart below and fax to ISMA at (317) 261-2235 or mail to ISMA
at 322 Canal Walk, Indianapolis, IN 46202.
To request this change:
Add dependents
Delete dependents
Request plan upgrade
Request review of risk
class
Change your name
Change your life
insurance beneficiary (if
you are in a group and
have Anthem life
insurance)
Complete these sections of Anthem Enrollment form:
Above Section A: Check the “Reclassification” box and write on line, “Add
dependents”.
Section A: Complete name and social security number.
Section B: Complete in full; check “Add” box at far right to indicate which
dependents you want to add. Check “Yes” or “No” boxes at bottom of
section as appropriate.
Sections C, D, E: Complete as questions pertain to the dependents you
want to add.
Section G: Sign and date.
Above Section A: Check the “Reclassification” box and write on line,
“Delete dependent(s)”.
Section A: Complete name and social security number.
Section B: Complete in full; check “Delete” box at far right to indicate which
dependents you want to delete.
Section G: Sign and date.
Section H: Complete for every dependent you want to delete. Sign and
date at bottom.
Above Section A: Check the “Reclassification” box and write on line,
“Request for plan upgrade”.
Section A: Complete name, social security number, height, weight,
Currently Hospitalized or Disabled?
Section B: Check box for the plan you want to change to. List Name, Sex,
Birth Date, Height, Weight, Currently Hospitalized/Disabled, for all covered
dependents.
Section C: Complete as questions pertain to you and all covered
dependents.
Section G: Sign and date.
Above Section A: Check the “Reclassification” box and write on line,
“Request for review of risk class”.
Section A: Complete name, social security number, height, weight,
Currently Hospitalized or Disabled?
Section B: Check box for the plan you want to change to. List Name, Sex,
Birth Date, Height, Weight, Currently Hospitalized/Disabled, for all covered
dependents.
Section C: Complete as questions pertain to you and all covered
dependents.
Section G: Sign and date.
Above Section A: Check the “Reclassification” box and write on line,
“Request name change”.
Section A: Complete new name, social security number.
Section G: Sign and date.
Above Section A: Check the “Reclassification” box and write on line,
“Request beneficiary change”.
Section A: Complete new name, social security number.
Section F: Check “Change” box and complete name, relationship and age
of primary beneficiary (contingent beneficiary info is optional).
Section G: Sign and date.
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C. HEALTH INFORMATION – MUST BE COMPLETED BY ALL ELIGIBLE EMPLOYEES
Simplified Medical: Groups with 15 or more enrolled health employees, please complete Section I. If any question on Section I is answered “Yes” please also complete Section II.
Full Medical: Groups with 14 or fewer enrolled health employees, please complete Section I and Section II and provide full details.
Please note that an individual will not be denied health coverage based upon the answers provided.
SECTION I: Simplified Medical Questions
1. Does any person for whom coverage is requested regularly take medication (prescription or other)?
M Yes M No
2. Has any person for whom coverage is requested been told by a doctor that surgery or special
medical tests or treatment might be required or necessary at some future date?
M Yes M No
F. Heart attack, stroke, angina, heart murmur, anemia, or any disorder of the heart, arteries,
veins, or circulatory system?
M Yes M No
G. Lupus, systemic or connective tissues disorder, arthritis, gout, polio, rheumatic fever,
multiple sclerosis, muscular dystrophy, carpal tunnel syndrome, or any muscular skeletal
disorder including any back condition, injury, disorder or deformity?
3. In the last five (5) years, has any person for whom coverage is requested been diagnosed or treated for any heart/
circulatory condition, cancer, Acquired Immune Deficiency Syndrome (AIDS), stroke, diabetes, mental or nervous
disorder, kidney, liver or pancreas disorder, emphysema, lung disorder, Chronic Obstructive Pulmonary
Disease (COPD), ulcerative colitis, Crohn’s disease, aneurysm, lupus, or rheumatoid arthritis?
M Yes M No
H. Epilepsy, convulsions, aneurysm, paralysis or disorder of the brain or nervous system?
M Yes M No
M Yes M No
I. Acquired Immune Deficiency Syndrome (AIDS), AIDS related complex (ARC), or disorder
of the blood or immune system?
M Yes M No
M Yes M No
J. Emphysema, bronchitis, COPD, asthma, sinus or nasal disorder, allergies, pneumonia,
or any other disorder of the lungs or respiratory system?
4. Is any family member currently pregnant? If yes, name _________________________________
Due Date ____________________________________
To the best of your knowledge, has anyone within the last five (5) years had a
diagnosis or treatment of the following:
M Yes M No
M. Any sexually transmitted diseases or disorder of the genital or urinary system?
A. Cancer, Hodgkin’s lymphoma, leukemia, tumor, growths or any diseases of the skin?
M Yes M No
B. Ulcers, stomach disorders, hernia, hemorrhoids, Crohn’s disease, ulcerative colitis, diverticulitis,
rectal disorder, irritable bowel syndrome or other intestinal disorders?
M Yes M No
C. Diabetes: If yes, name of person: __________________________________________________
M Yes M No
Type:_________________ Age of onset: ___________ Treatment________________________
M Yes M No
M Yes M No
D. Liver, pancreas, kidney, gallbladder, or prostate disorder?
E. High blood pressure, elevated cholesterol or triglycerides?
Person
O. Any other medical or surgical advice, treatment or hospitalization or departure
from good health not mentioned in any of the questions above?
L. Thyroid, goiter, or disorder of the endocrine system, or sugar or albumin in the urine?
SECTION II: FULL Medical Questions
Condition and
Item Number
N. Any disorder of the eyes, ears, nose or throat?
M Yes
M Yes
M Yes
M Yes
M Yes
K. Alcoholism, drug abuse, depression, or mental or nervous disorder?
Dates
Hospitalized
Yes
No
Surgery
Performed?
Yes
No
M No
M No
M No
M No
M No
P. Has anyone smoked cigarettes in the last twelve months? If yes, name of person _________________ M Yes M No
Q. Have you or your eligible dependents, within the last two years, engaged in skydiving, hang gliding,
underwater diving, racing (any type), rodeo, mountaineering, professional sports,
piloting a plane, or are any such activities contemplated?
M Yes M No
Please provide complete details to all “Yes” answers given above in the box provided below.
Treatment
Date of Last
Treatment
Present Condition
Physician’s Name
Your Last Name _________________________________Date __________________
35-99-MED-ISMA
D. PRIOR HEALTH COVERAGE
Have you and/or your dependents had prior coverage within the last 18 months? M Yes M No
If so, and you wish to receive Pre-existing Credit for such coverage, please provide a Certificate of Health Coverage from your prior carrier(s) and complete the following:.
Name of Insurance Carrier(s) _________________________________________________________________________________________________________ Group Number ______________________________________________________________
Policy/Certificate Number ___________________________________________________ Effective Date ______________________________ Is Coverage Still In Effect? M Yes M No
M Divorce or legal separation
Reason for Termination:
M Employment terminated
M Death of spouse
M Group plan terminated
M COBRA coverage exhausted
If No, Termination date __________________________
M Employer contribution ceased
M Other
Date coverage ended __________________________________ List any dates when coverage was not in force ________________________________________________________________
E. OTHER HEALTH COVERAGE WHICH YOU OR YOUR DEPENDENTS HAVE
1. Are you or any listed dependent presently enrolled in any other type of Health coverage or HMO?
M Yes M No If yes, complete the following questions:
HMO Name _____________________________________________________________________________________
Insurance Company Name __________________________________________________________________________
2. I am eligible for
M Medicare M Medicaid
Medicare or Medicaid Number is _______________________
For Hospital coverage (Part A), effective date is _________________________________________________________
For Medical coverage (Part B), effective date is _________________________________________________________
Reason for entitlement: M Age M Disability M End Stage Renal Disease (ESRD) M ESRD & Disability
ESRD Onset Date _________________________________________________________________________________
3.
4.
5.
6.
Name of person with other coverage __________________________________________________________________
Relationship to applicant __________________________________________________________________________
Type of coverage M Health M Prescription Drug M Dental M Vision M Other – Explain _________________
Covered person’s Social Security No. _________________________________________________________________
Policy No. if different from Social Security No. _________________________________________________________
7. Covered person’s Birthday: Month _________________________Day _____________Year ____________________
8. Name of covered person’s employer __________________________________________________________________
9. Employer’s address _______________________________________________________________________________
City/State/Zip ____________________________________________________________________________________
F. LIFE INSURANCE — LIFE INSURANCE PRODUCTS ARE UNDERWRITTEN BY ANTHEM LIFE INSURANCE COMPANY OF INDIANA.
Beneficiary for Life Insurance: M New M Change
FOR GROUPS OF 3 OR MORE ONLY
Life Options:
M Employee Life/AD&D
M Short-term Disability
M Dependent Life
M Long-term Disability
Primary Name ___________________________________________________________________________________
Relationship _____________________________________________________________ Age _____________
Contingent Name _________________________________________________________________________________
Please provide the following information: Salary information: $ _______________________
Please check pay mode: M Hourly M Weekly M Monthly M Annually
Accidental Death and Dismemberment coverage amount equals amount of Basic Term Life Coverage
Relationship _____________________________________________________________ Age _____________
(Example: “Helen Louise Jones” – Not “Mrs. H.L. Jones” Relationship: Wife)
PLEASE COMPLETE REVERSE SIDE
FOR INTERNAL USE ONLY: Effective Date of Coverage:____________________ By: __________________________________________ Pre-existing Time Remaining: _____________________
Late or Timely:
BILL CYCLE
Group M
35-99-MED-ISMA
If timely, please provide the date of the event and check the event:
Date of Event:
Event:
M Association Membership
M Marriage
M New Hire
M New Born
Other:
M
Q
S
Individual M
Y
For Life Coverage: Multi Bill Code _________________
M Divorce
M New Adoption
M Death of a spouse
Probationary Period: M None
M 30 Days
M 90 Days
HEALTH CLASS
RECEIVED DATE
MAST ID
RECORD #
AGENT
MED. EDUC. #
1ST PAYMENT
ACCOUNT #
M 60 Days
M Other
C. HEALTH INFORMATION – MUST BE COMPLETED BY ALL ELIGIBLE EMPLOYEES
Simplified Medical: Groups with 15 or more enrolled health employees, please complete Section I. If any question on Section I is answered “Yes” please also complete Section II.
Full Medical: Groups with 14 or fewer enrolled health employees, please complete Section I and Section II and provide full details.
Please note that an individual will not be denied health coverage based upon the answers provided.
SECTION I: Simplified Medical Questions
1. Does any person for whom coverage is requested regularly take medication (prescription or other)?
M Yes M No
2. Has any person for whom coverage is requested been told by a doctor that surgery or special
medical tests or treatment might be required or necessary at some future date?
M Yes M No
F. Heart attack, stroke, angina, heart murmur, anemia, or any disorder of the heart, arteries,
veins, or circulatory system?
M Yes M No
G. Lupus, systemic or connective tissues disorder, arthritis, gout, polio, rheumatic fever,
multiple sclerosis, muscular dystrophy, carpal tunnel syndrome, or any muscular skeletal
disorder including any back condition, injury, disorder or deformity?
3. In the last five (5) years, has any person for whom coverage is requested been diagnosed or treated for any heart/
circulatory condition, cancer, Acquired Immune Deficiency Syndrome (AIDS), stroke, diabetes, mental or nervous
disorder, kidney, liver or pancreas disorder, emphysema, lung disorder, Chronic Obstructive Pulmonary
Disease (COPD), ulcerative colitis, Crohn’s disease, aneurysm, lupus, or rheumatoid arthritis?
M Yes M No
H. Epilepsy, convulsions, aneurysm, paralysis or disorder of the brain or nervous system?
M Yes M No
M Yes M No
I. Acquired Immune Deficiency Syndrome (AIDS), AIDS related complex (ARC), or disorder
of the blood or immune system?
M Yes M No
M Yes M No
J. Emphysema, bronchitis, COPD, asthma, sinus or nasal disorder, allergies, pneumonia,
or any other disorder of the lungs or respiratory system?
4. Is any family member currently pregnant? If yes, name _________________________________
Due Date ____________________________________
To the best of your knowledge, has anyone within the last five (5) years had a
diagnosis or treatment of the following:
M Yes M No
M. Any sexually transmitted diseases or disorder of the genital or urinary system?
A. Cancer, Hodgkin’s lymphoma, leukemia, tumor, growths or any diseases of the skin?
M Yes M No
B. Ulcers, stomach disorders, hernia, hemorrhoids, Crohn’s disease, ulcerative colitis, diverticulitis,
rectal disorder, irritable bowel syndrome or other intestinal disorders?
M Yes M No
C. Diabetes: If yes, name of person: __________________________________________________
M Yes M No
Type:_________________ Age of onset: ___________ Treatment________________________
M Yes M No
M Yes M No
D. Liver, pancreas, kidney, gallbladder, or prostate disorder?
E. High blood pressure, elevated cholesterol or triglycerides?
Person
O. Any other medical or surgical advice, treatment or hospitalization or departure
from good health not mentioned in any of the questions above?
L. Thyroid, goiter, or disorder of the endocrine system, or sugar or albumin in the urine?
SECTION II: FULL Medical Questions
Condition and
Item Number
N. Any disorder of the eyes, ears, nose or throat?
M Yes
M Yes
M Yes
M Yes
M Yes
K. Alcoholism, drug abuse, depression, or mental or nervous disorder?
Dates
Hospitalized
Yes
No
Surgery
Performed?
Yes
No
M No
M No
M No
M No
M No
P. Has anyone smoked cigarettes in the last twelve months? If yes, name of person _________________ M Yes M No
Q. Have you or your eligible dependents, within the last two years, engaged in skydiving, hang gliding,
underwater diving, racing (any type), rodeo, mountaineering, professional sports,
piloting a plane, or are any such activities contemplated?
M Yes M No
Please provide complete details to all “Yes” answers given above in the box provided below.
Treatment
Date of Last
Treatment
Present Condition
Physician’s Name
Your Last Name _________________________________Date __________________
35-99-MED-ISMA
D. PRIOR HEALTH COVERAGE
Have you and/or your dependents had prior coverage within the last 18 months? M Yes M No
If so, and you wish to receive Pre-existing Credit for such coverage, please provide a Certificate of Health Coverage from your prior carrier(s) and complete the following:.
Name of Insurance Carrier(s) _________________________________________________________________________________________________________ Group Number ______________________________________________________________
Policy/Certificate Number ___________________________________________________ Effective Date ______________________________ Is Coverage Still In Effect? M Yes M No
M Divorce or legal separation
Reason for Termination:
M Employment terminated
M Death of spouse
M Group plan terminated
M COBRA coverage exhausted
If No, Termination date __________________________
M Employer contribution ceased
M Other
Date coverage ended __________________________________ List any dates when coverage was not in force ________________________________________________________________
E. OTHER HEALTH COVERAGE WHICH YOU OR YOUR DEPENDENTS HAVE
1. Are you or any listed dependent presently enrolled in any other type of Health coverage or HMO?
M Yes M No If yes, complete the following questions:
HMO Name _____________________________________________________________________________________
Insurance Company Name __________________________________________________________________________
2. I am eligible for
M Medicare M Medicaid
Medicare or Medicaid Number is _______________________
For Hospital coverage (Part A), effective date is _________________________________________________________
For Medical coverage (Part B), effective date is _________________________________________________________
Reason for entitlement: M Age M Disability M End Stage Renal Disease (ESRD) M ESRD & Disability
ESRD Onset Date _________________________________________________________________________________
3.
4.
5.
6.
Name of person with other coverage __________________________________________________________________
Relationship to applicant __________________________________________________________________________
Type of coverage M Health M Prescription Drug M Dental M Vision M Other – Explain _________________
Covered person’s Social Security No. _________________________________________________________________
Policy No. if different from Social Security No. _________________________________________________________
7. Covered person’s Birthday: Month _________________________Day _____________Year ____________________
8. Name of covered person’s employer __________________________________________________________________
9. Employer’s address _______________________________________________________________________________
City/State/Zip ____________________________________________________________________________________
F. LIFE INSURANCE — LIFE INSURANCE PRODUCTS ARE UNDERWRITTEN BY ANTHEM LIFE INSURANCE COMPANY OF INDIANA.
Beneficiary for Life Insurance: M New M Change
FOR GROUPS OF 3 OR MORE ONLY
Life Options:
M Employee Life/AD&D
M Short-term Disability
M Dependent Life
M Long-term Disability
Primary Name ___________________________________________________________________________________
Relationship _____________________________________________________________ Age _____________
Contingent Name _________________________________________________________________________________
Please provide the following information: Salary information: $ _______________________
Please check pay mode: M Hourly M Weekly M Monthly M Annually
Accidental Death and Dismemberment coverage amount equals amount of Basic Term Life Coverage
Relationship _____________________________________________________________ Age _____________
(Example: “Helen Louise Jones” – Not “Mrs. H.L. Jones” Relationship: Wife)
PLEASE COMPLETE REVERSE SIDE
FOR INTERNAL USE ONLY: Effective Date of Coverage:____________________ By: __________________________________________ Pre-existing Time Remaining: _____________________
Late or Timely:
BILL CYCLE
Group M
35-99-MED-ISMA
If timely, please provide the date of the event and check the event:
Date of Event:
Event:
M Association Membership
M Marriage
M New Hire
M New Born
Other:
M
Q
S
Individual M
Y
For Life Coverage: Multi Bill Code _________________
M Divorce
M New Adoption
M Death of a spouse
Probationary Period: M None
M 30 Days
M 90 Days
HEALTH CLASS
RECEIVED DATE
MAST ID
RECORD #
AGENT
MED. EDUC. #
1ST PAYMENT
ACCOUNT #
M 60 Days
M Other
G. PLEASE SIGN AND DATE THE APPLICATION ON THE LINES BELOW
Pre-Notice Regarding the Medical Information Bureau:
Information regarding your insurability will be treated as confidential. Anthem Life Insurance Company of Indiana or its reinsurer(s)
may, however, make a brief report thereon to the Medical Information Bureau, a non-profit membership organization of life insurance
companies, which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life
or health insurance coverage, or a claim for benefits is submitted to such a company, the Bureau, upon request, will supply such company or its reinsurers with the information in its file.
Upon receipt of a request from you, the Bureau will arrange disclosure of any information in its file. (Medical information will be disclosed only to your attending physician.) If you question the accuracy of information in the Bureau’s file, you may contact the Bureau
and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of the Bureau’s
information office is Post Office Box 105, Essex Station, Boston, Massachusetts 02112, telephone number (617) 426-3660.
I hereby authorize my employer to deduct from my pay any contributions required for my coverage. I represent that all answers and
statements on this application including any attached papers, are true and complete to the best of my knowledge and belief. I understand
that any misstatements or failure to report new medical information prior to my effective date may result in a material change to my coverage or premium rates.
I wish to apply for the coverage selected on this application. If I select a coverage, or combination of coverages, not available to me
and/or a class for which I am not eligible, I agree that my selection(s) is hereby automatically amended to be consistent with the Group’s
application. I understand that I may not assign any payment under my Anthem Blue Cross and Blue Shield program. I agree that, in the
Proxy Statement:
I understand that the Annual Meeting of the Members of Anthem Insurance Companies, Inc. will be held on the fourth
Thursday of March each year at Anthem’s principal office in Indianapolis, Indiana at 11:00 a.m., or at such other date,
place (within or outside the State of Indiana) or time as may be designated by the Board of Directors upon notice to the
Members. I also understand that Special Meetings of the Members of Anthem may be held from time to time upon prior
notice giving the place, day, hour and purposes for any such Special Meeting. I understand that I may vote at any Annual
Meeting or any Special Meeting in person or by proxy. I hereby voluntarily grant my proxy to the Board of Directors of
Anthem to vote on my behalf at any and all Meetings of the Members of Anthem. I understand that my granting of the
proxy is not a condition of membership and that my proxy only becomes effective upon my acceptance as a Member by
Anthem. I understand that, without limit as to time, this proxy to Anthem’s Board of Directors will remain in effect until I
normal course of business, Anthem Insurance Companies, Inc., and/or Anthem Life Insurance Company of Indiana and their designated
contractors may obtain any and all reports and records or copies thereof concerning any injury, illness, or condition for which service
was provided to me or my eligible dependents after this date, together with like reports and records or copies thereof of earlier services,
for purposes of processing this application and for purposes of determining the eligibility of any claim for payment or the propriety of
any payment made. I authorize Hospitals, Physicians, or other Providers of service, having such information to furnish it to Anthem
Insurance Companies, Inc., and/or Anthem Life Insurance Company of Indiana and its designated contractors. This information will be
used for purposes which include but are not limited to: processing this application for enrollment; group risk classification; detecting or
preventing fraud or misrepresentation; internal and external audits; administration of claims; case management; quality assurance and
audits; utilization review; coordination of benefits; subrogation; health promotion, disease management/prevention, and any other
managed care/prevention program. I authorize the Medical Information Bureau, Inc., having such information to furnish it to Anthem
Life Insurance Company of Indiana and its designated contractors. I also agree that in the normal course of its business, Anthem
Insurance Companies, Inc., and/or Anthem Life Insurance Company of Indiana may furnish to their designated contractors, the Group,
and the designated contractors of the Group, information relating to medical services and treatment rendered to me and my eligible
dependents, except as prohibited by law. I understand that my coverage will not begin until the date shown on my Identification Card. I
also understand that a claim of mine may be denied or my coverage canceled or nullified if it is determined I gave false information on this application or with a claim for payment.
Sign Here X ________________________________________________________________ Date ____________________________
Employee
revoke it or until I am no longer a Member of Anthem. I also understand that I may revoke this proxy by attending any
meeting of the Members of Anthem or by sending a written revocation to the attention of the Corporate Secretary of
Anthem at its principal office in Indianapolis, Indiana. The revocation of this proxy by my attendance at any Meeting
shall operate to revoke this proxy for that Meeting only. A written revocation shall be effective only for Meetings held
after Anthem’s receipt thereof.
Directions: please check the applicable box and sign below.
M Yes, I grant my proxy to the Board of Directors of Anthem.
M No, I do not grant my proxy to the Board of Directors of Anthem.
Signature X ___________________________________________________ Date ______________________
H. WAIVER OF GROUP HEALTH INSURANCE
I hereby certify that I have been given the opportunity to apply for the available group health
benefits offered by my employer, the benefits have been explained to me, and I and/or my
dependent(s) decline to participate. Neither I nor my dependent(s) were induced or pressured
by my employer, agent, or health carrier, into declining this coverage, but elected of my (our)
own accord to decline coverage.
LATE ENROLLMENT
I understand that if I and/or my dependent(s) make application for such coverage at a future
date, and I and/or my dependent(s) am/are considered to be late enrollees, I and/or my dependent(s) may be subject to a preexisting conditions exclusion period which shall not exceed 18
months for groups of 51 or more eligible full time employees, or 15 months for groups of 50 or
fewer eligible full time employees, from the date of enrollment (subject to reduction for prior
creditable coverage, as applicable).
Name of Person Declining/Relationship
(please use an additional sheet if needed)
SPECIAL ENROLLMENT
I and/or my dependent(s) will not be considered late enrollees when applying at a future date, if the following conditions are met:
1. I and/or my dependent(s) declined this coverage due to other health coverage;
2. the other health coverage was:
a. COBRA continuation which exhausted; or
b.terminated as a result of loss of eligibility for that coverage (due to legal separation, divorce, death, termination of employment, or reduction
in the number of hours of employment); or terminated as a result of employer contributions towards such coverage ceasing; and
3. enrollment under this coverage is requested no later than 30 days after the date of coverage described in 2. a. or b. above terminated.
In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll my dependent(s),
provided I request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
Reason for Declination
Type of Existing Coverage & Carrier Name
__________________________________________________
______________________________________
Signature of Employee Waiving Coverage
____________________
Social Security Number
Date
35-99-MED-ISMA
Medical
An independent licensee of the Blue Cross and Blue Shield Association.
Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.
® Registered marks Blue Cross and Blue Shield Association
M
M
M
M
Health Insurance underwritten by Anthem Insurance Companies, Inc.
Life Insurance underwritten by Anthem Life Insurance Company of Indiana,
an independent licensee of the Blue Cross and Blue Shield Association.
M Application for COBRA continuation
M Reclassification/change of
membership/change of name
State reason and date of event:
_________________________________
New application
Waiver of health coverage
Request for reinstatement
Change in life benefits
(See Section F.)
TO AVOID DELAYS IN PROCESSING PLEASE ANSWER EACH OF THE FOLLOWING QUESTIONS IN DETAIL. PLEASE PRINT AND SIGN IN INK.
A. MEMBER INFORMATION
Last Name ______________________________________________ First _______________________________________ Middle ______________________ Social Security Number _______________________________
Street (Residence) _____________________________________________________________ City __________________________________ State __________________ Zip ________________ State of Birth __________
Work Telephone (
) _________________ Birth Date (Mo/Day/Year) ___________________ Age _______ Height ________ Weight________ M Male M Female M Single M Married M Widowed M Divorced
Currently Hospitalized or Disabled? M Yes M No
Are you currently actively at work? M Yes M No If no, please state reason. _______________________________________________________________________
Are you or any of your dependents covered or eligible for an employer group plan as a result of COBRA? M Yes M No If yes, please explain. ________________________________________________________________
Current
Effective Date of COBRA ______________________ Qualifying Event ______________________________________ Employer Size:
M Less than 20 employees on payroll
M More than 20 employees on payroll
Employer’s Name and Address
Wages reported by:
M W2 M 1099
M Other ____________
Date Employed
Full Time
/
Hours worked
per week
/
Premiums Paid By
Occupation
M Employer M Both
M Employee
B. YOUR COVERAGE OPTION
I request the following M 250 PPN M 500 PPN
coverage option:
M 1000 PPN M 2000 PPN M 5000 PPN M Dental
MSA: M PPN
M 250 Trad. M 500 Trad. M 1000 Trad. M 2000 Trad. M 5000 Trad. M Medicare Supplement
M Trad.
M Life Products
(see Section F)
Premium Notice to:
Claim Information to:
M Home
M Home
M Office
M Office
Coverage includes: M Member Only M Member and Child(ren) M Member and Spouse M Member and Dependents (Spouse and Child(ren))
Dependents:
Last Name
First Name
Middle
Initial
Social Security Number
Relationship
Sex
M F
Birth Date
Mo Da Yr
Age
Are over age disabled dependents to be covered?
M Yes M No If yes, complete a Certification Form and submit with this
Are children or stepchildren from a previous marriage to be covered?
M Yes M No application (available through ISMA).
If your dependent is not eligible to be claimed on your Federal Income Tax Forms, attach a copy of the court decree or the Qualified Medical Child Support Order.
35-99-MED-ISMA
Height
Weight
Is your dependent
Currently
listed on your Federal
Hospitalized/ Income Tax forms?
Disabled? If no, please see below. Reclassification
Yes
No
Yes
No
Add Delete
List the names of the stepchildren:
____________________________________________
____________________________________________