United Healthcare Small Business
Employee Enrollment Form
Name
*
First Name
Last Name
MI
Social Security Number
*
Cell Phone
*
Format: (000) 000-0000.
Address
*
Address
Street Address Line 2
City
State/Zip
Postal / Zip Code
Date of Birth
*
Preferred Language
English
Spanish
Chinese
Vietnamese
Korean
Other
Sex
Female
Male
Undisclosed
Have you ever been a member of United Healthcare
*
Please Select
Yes
No
Email Address
*
example@example.com
Subscriber Last, First Name
*
SSN
*
Medical Plan Description
*
Please Select
HMO
PPO
Subscriber Last, First Name
*
SSN
*
I understand that I am completing a health application and, to the best of my knowledge, that each response is complete and accurate. I (we) request the indicated group medical coverage. I authorize any required premium contributions to be deducted from my earnings. I (we) understand that UnitedHealthcare is not bound by any statements I (we) have made to any agent or to any other persons, if those statements are not written or printed on this application and any attachments. Please maintain a copy of this authorization for your records. Please note that if UnitedHealthcare can demonstrate you committed an act or practice that constituted fraud, or an intentional misrepresentation of a material fact, UnitedHealthcare may rescind your coverage. UnitedHealthcare will issue a written notice via regular certified mail at least 30 days prior to the effective date of the rescission explaining the basis for the decision of rescission and your appeal rights. No agreement /policy will be rescinded after 24 months following the issuance of the agreement/policy. In addition, in the event it is found you committed an act or practice that constituted fraud, or an intentional misrepresentation of a material fact, UnitedHealthcare may cancel your coverage, as permitted by law. I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention health or health-related procedures, products and services that might be valuable to me and otherwise as permitted by law.
*
Type Name
Employee Signature (if applying for coverage)
*
Date
*
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