I hereby request coverage for me and all dependents as indicated on this form and authorize my employer to make necessary deductions from my earnings unless indicated otherwise. I understand that if I do not enroll when first eligible, I will not be able to obtain coverage in the future except at annual enrollment or within 30 days of a family status change as listed below:
1. Marriage; 2. Divorce or legal separation; 3. Death of a spouse or dependent; 4. Birth or adoption of a child; 5. Termination or commencement of spouse’s employment; 6. A change in employment status of the employee or his/her spouse from part-time to full-time or full-time to part-time; 7. The taking of an unpaid leave of absence by the employee or his/her spouse; 8. A significant change in the health coverage of the employee or his/her spouse’s employment.
I certify that all the information furnished by me is true and correct. I understand that if I have provided any false, incomplete or misleading information, then my coverage under this plan may result in a denial of all benefits. I understand that all benefits are subject to the terms and conditions stated in the certificates.
Notice: a person may be committing insurance fraud if he or she submits an application or claim containing a false or deceptive statement with intent to defraud (or knowing that he or she is helping to defraud) an insurance company.
I hereby authorize all providers, Third Party Payers, utilization review agencies, my employer and state or federal agencies to exchange all demographic, medical, mental health, AIDS and HIV, and substance abuse information as necessary for claims processing, clinical studies, care management, plan administration, or benefit administration. I understand any information will be used only after issuance of plan coverage and will have no effect on determination of eligibility to enroll. I give this consent for myself and any eligible family member listed on this application for who I am authorized to do so. I understand that failure to sign this authorization may be a basis for enrollment or benefit denial. I understand that I am entitled to receive a copy of this authorization. I further understand that this authorization will remain in effect until coverage under the plan ends or I give written notice to carrier that I want to revoke this authorization. I understand the revocation of this authorization may be a basis for denying benefits.