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.
  •  - -
  •  - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  •  - -

  • 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.
  • Rows

  • 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.

  • 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.)

    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.
  • Rows
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Removals

  • 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.
  • Rows
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Attest

  • When was the last time you were covered by insurance?

  •  - -
  •  - -

  • Explanation or Comments

  • 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) understand that this PEHP plan does not allow for double coverage and agree to cancel any other Medical and/or Dental insurance for myself and any dependents if approved for Medical and/or Dental coverage under this plan; and (6) agree to the terms and conditions in the PEHP Master Policy.

  • *   

  •  - -
  • Should be Empty: