Volunteer EMS Insurance Application

Volunteer EMS Insurance Application

Enrollment and Change Form
Program Eligibility Questions?

Please contact the Utah Association of Counties at (801) 265-1331 or ems@uacnet.org. General information can also be found at www.uacnet.org/rural-ems-insurance.
Plan Coverage Inquiries?

Please call PEHP at (801) 366-7555. A coverage packet can also be found at www.uacnet.org/rural-ems-insurance.
Type of Application*

New Enrollment: If you don't have PEHP Volunteer EMS Insurance but would like it.Change Request: If you have PEHP Volunteer EMS Insurance and would like to make changes, including adding or removing benefits or dependents.
Reason for Change Request*
Date for Change Implementation*

MonthDayYear
Name*

First NameLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Marital Status*

SingleMarried
Gender*

MaleFemale
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
Alternate Phone Number
County Volunteering In*
Agency Volunteering For *
If your agency is not listed, you are not eligible for this insurance program. You can call 801-265-1331 if you have questions.
EMT, AEMT, or Paramedic License Number*
According to Utah Code 53-2d-402
License Expiration Date*

MonthDayYear
Basic Group Term Life Insurance Coverage

Basic Life Insurance benefit provides the following coverage $50,000 (death of participant); $10,000 (accidental death); $50,000 (line of duty death); $50,000 (accidental death and disability); $10,000 (death of spouse or child). Coverage amounts are reduced at age 71.
Would you like Basic Group Term Life Insurance Coverage (provided at no cost to volunteer)?*

YesNo

Considerations When Naming Beneficiaries

1. List ALL beneficiaries. Beneficiary payments are paid from the most recent beneficiary designation on file with PEHP.

2. Types of beneficiaries:

A. Primary - Person to receive the death benefits upon the death of the member.

B. Contingent - Person to receive the death benefits upon the death of the memer if the primary beneficiary is deceased.

3. If you name multiple primary beneficiaries, the proceeds will be split equally, unless otherwise instructed on the form.

4. If your primary beneficiary(ies) dies before you and you have not named a continget beneficiary, the proceeds may be subject to Title 75, Chapter 2 of the Utah Uniform Probate Code.

5. If you name a trust as beneficiary, be sure to list the name of the trustee and the date the trut agreement became effective.

6. Proceeds may not be paid directly to a minor child. In the event a minor child is named a beneficiary, proceeds must be paid to a trust, conservatorship or legal guardian.
Long Term Disability

Benefit provides $1,000/month long-term disability benefit (for the volunteer only). URS Post Retirees are NOT eligible for this benefit pursuant to Utah Code 49-21-102.
Would you like Long-Term Disability Coverage (provided at no cost to volunteer)?*

YesNo
Medical Health Insurance
Would you like PEHP Volunteer EMS Medical Insurance?*

YesNo
Group Medical (Medical Plans Using In-network & Out-of-Network Providers. Check one)*

Summit NetworkAdvantage Network
Medical Coverage Type*

Volunteer Only ($0.00/month)Volunteer Plus One Dependent ($92.52/month)Volunteer Plus Two or More Dependents ($182.39/month)
Dental Insurance
Would you like PEHP Volunteer EMS Dental Insurance?*

YesNo
Group Dental*

Preferred Dental Care
Dental Coverage Type*

Volunteer Only ($0.00/month)Volunteer Plus One Dependent ($4.52/month)Volunteer Plus Two or More Dependents ($13.17/month)
Additions
If you would like your family members covered, please add them here. (Skip this section if you want the insurance for yourself only.)

List your eligible dependents for Medical and/or Dental Coverage. If adding a new spouse, include a copy of marriage certificate. If dependents are stepchildren, natural children not living with both parents, or "other" relationship, provide supporting documentation, e.g., divorce decree, court orders, birth certificate, etc. If you don't have supporting documentation, please explain in the "Explanation or Comments" section later in form. If you have more than five dependents, please list them and their required information in the "Explanation or Comments" section later in form.

File Upload for Additions (Marriage Certificate or Other Dependent Supporting Documentation)

Cancelof
Removals
Do you need to remove someone from your current EMS Volunteer PEHP insurance coverage due to divorce, death, children who have recently turned 26 years old or older, or enrolling in other coverage?*

YesNo
Removals

If you are terminating coverage for dependents who are no longer eligible due to divorce, death, children who are 26 years old or older, or enrolling in other coverage, please fill out the information below. For all terminations outside of the annual enrollment period, documentation is required (divorce decree, death certificate, birth certificate, proof of other coverage, etc.). If you voluntarily drop dental coverage, you will not be able to re-enroll for up to three years.

File Upload for Removals (divorce decree, death certificate, birth certificate, proof of other coverage, etc.)

Cancelof
Attest
Are you or your spouse currently covered by medical/health insurance (other than PEHP's EMS Volunteer Insurance, if applicable)?*

YesNo
Are you or your spouse currently eligible for medical/health coverage through your employer, your parents' employer, Medicaid, Medicare or the Veteran's Administration?*

YesNo
Does the monthly cost of your current medical/health coverage exceed the following amounts: $145.21 for Single Coverage $273.37 for Double Coverage $351.30 for Family Coverage*

YesNo
Cost of Other Available Insurance*
Source of Other Available Insurance*
Are you or your spouse currently covered by dental insurance (other than PEHP's Volunteer EMS Dental Insurance, if applicable)?*

YesNo
Are you or your spouse currently eligible for dental coverage through your employer, your parents' employer, Medicaid, Medicare, or the Veteran's Administration?*

YesNo
Does the monthly cost of your current dental coverage exceed the following amounts: $9.85 for Single Coverage $12.56 for Double Coverage $17.75 for Family Coverage*

YesNo
Cost of Other Available Insurance*
Source of Other Available Insurance*
When was the last time you were covered by insurance?
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Name of Health Plan
Reason for Termination
Explanation for Last Insurance Termination
Explanation or Comments
Explanation or Comments for any piece of this application
Volunteer Agreement and Signature
Before signing, make sure that all applicable sections are complete so your enrollment is not delayed. You may be asked to provide additional information and/or documentation. Please note: It is the volunteer's responsibility to notify PEHP within 60 days of any changes affecting coverage and/or dependent eligibility (e.g., birth, marriage, divorce, etc.).

I represent that all information is true and correct. I understand and agree that any false information I provide on this form may, at PEHP's sole discretion, result in a limitation or termination of my coverage. By signing below I hereby: (1) authorize the deduction of health/dental contributions through the provisions of IRS Section 125 Flexible Benefits if applicable; (2) authorize PEHP to release information to health/dental providers, insurance entities, or other entities necessary to process claims and to administer the health plan; (3) certify all dependents listed are eligible for coverage; (4) understand if PEHP is not notified that a dependent is ineligible and subsequent claims are paid, I will be responsible for reimbursement to PEHP for any claims paid in error; (5) agree to the terms and conditions in the PEHP Master Policy.
I certify that I am not a party to a divorce proceeding and am not subject to an injunction/order which prevents me from modifying insurance or changing beneficiaries.*

Check box to certify
Signature*
Typed Name*
Date*

MonthDayYear
Date
Should be Empty:

	Full Name of Beneficiary (Last, First, Middle initial)	Relationship to Volunteer (Legal Spouse, Child Natural/Adopted, Stepchild, or Other: Describe in Explanation)	Designation (Primary OR Contingent)	Birth Date (mm/dd/yy)	Mailing Address (Street, City, State, Zip)
Beneficiary One
Beneficiary Two
Beneficiary Three

	Relationship to Volunteer: Legal Spouse, Natural or Adopted Child, Stepchild, or Other (Describe in Explanation)	Full Name of Dependents (Last, First, Middle Initial)	If Legal Spouse, Marriage Date (mm/dd/yy)	Gender (Male/Female)	Birth Date (mm/dd/yy)	Social Security Number	Medical Coverage, Dental Coverage, or Both
Dependent One
Dependent Two
Dependent Three
Dependent Four
Dependent Five

	Relationship to Volunteer: Legal Spouse, Natural or Adopted Child, Stepchild, or Other (Describe in Explanation)	Full Name of Dependents (Last, First, Middle Initial)	Social Security No.	Reason for Termination (divorce, death, age of 26, other coverage, etc.)	Applicable Date (date of divorce, death, birthday, other coverage, etc.)
Dependent One
Dependent Two
Dependent Three
Dependent Four
Dependent Five

Volunteer EMS Insurance Application

Program Eligibility Questions?

Plan Coverage Inquiries?

Basic Group Term Life Insurance Coverage

Long Term Disability

Medical Health Insurance

Dental Insurance

Additions

If you would like your family members covered, please add them here. (Skip this section if you want the insurance for yourself only.)

Removals

Removals

Attest

When was the last time you were covered by insurance?

Explanation or Comments

Volunteer Agreement and Signature