Employee First Name *

Employee Last Name *

Marital Status *

Height and weight (i.e 150lbs, 5'10) *

Residence Address *

State and Zipcode *

Best time to contact (if additional information is required) *

Date of Birth (mm/dd/yy) *

Telephone number (include area code) *

Date of Hire *

Social Security Number *

Employed By *

Email Address *

Occupation *

Employee Waiver

Please check off if you are waiving enrollment in employer benefit plan

Please check off one of the sections below.

I Am Enrolling for:

Self Only

Self And Spouse

Self And Children

Self, Spouse And Children

Explanation for not enrolling spouse, children or both (255 max characters):

I understand I have the right to enroll my dependents at this time. I am voluntarily declining to enroll my dependents and have not been induced or pressured by anyone to decline such coverage. I understand that, if I do not enroll my dependents at this time, and they do not have other qualifying coverage, their right to enroll in the future may be restricted, with a delayed effective date or an extended Pre-Existing Condition Limitation Period.

Participation Information Complete for each person to be enrolled (use additional sheet if necessary)

Please fill in all fields for additional plan members.

	NAMES OF PARTICIPANTS	RELATIONSHIP	SEX	HEIGHT	WEIGHT	DATE OF BIRTH	SOCIAL SECURITY NUMBER
1	NAMES OF PARTICIPANTS	RELATIONSHIP	SEX	HEIGHT	WEIGHT	DATE OF BIRTH	SOCIAL SECURITY NUMBER
2	NAMES OF PARTICIPANTS	RELATIONSHIP	SEX	HEIGHT	WEIGHT	DATE OF BIRTH	SOCIAL SECURITY NUMBER
3	NAMES OF PARTICIPANTS	RELATIONSHIP	SEX	HEIGHT	WEIGHT	DATE OF BIRTH	SOCIAL SECURITY NUMBER
4	NAMES OF PARTICIPANTS	RELATIONSHIP	SEX	HEIGHT	WEIGHT	DATE OF BIRTH	SOCIAL SECURITY NUMBER
5	NAMES OF PARTICIPANTS	RELATIONSHIP	SEX	HEIGHT	WEIGHT	DATE OF BIRTH	SOCIAL SECURITY NUMBER

Section 2 - Other Coverage

Do you or your dependents have coverage under any health benefit plan? *

YES

NO

Coverage type *

Comprehensive Major Medical

Other (please provide copy of the benefit plan or schedule of benefits)

Name of Health Plan *

Health Plan Phone Number *

Effective Date of Prior Coverage *

Termination Date *

Reason for Coverage Termination *

Plan Type *

Employer Sponsored

Individual

Employer Name *

Policy/Cert. Number *

Coverage was for: *

Self

Spouse

Children

Section 3 - Medical History

1. In the past 5 years, have you or anyone enrolling for coverage had a diagnosis of or consultation, treatment or medication for:

Brain or Nervous System *

YES

NO

Chest Pain or Stroke *

YES

NO

Liver, Pancreas or Kidney *

YES

NO

Endocrine or Adrenal Disorder *

YES

NO

Abnormal Blood Pressure *

YES

NO

Skin or Collagen Disease *

YES

NO

Disease of the Muscles *

YES

NO

Heart or Circulatory System *

YES

NO

Blood Disorder *

YES

NO

Lymphatic Vessels or Glands *

YES

NO

Cirrhosis or Hepatitis *

YES

NO

Leukemia or Hodgkin’s Disease *

YES

NO

Cancer (Excluding Basal Cell Carcinoma) *

YES

NO

Breast or Reproductive Organs *

YES

NO

Multiple Sclerosis or Cystic Fibrosis *

YES

NO

Diabetes or Sugar in Urine *

YES

NO

Rheumatoid Arthritis *

YES

NO

Autoimmune Disorders *

YES

NO

Digestive or Gastrointestinal Disorder *

YES

NO

Disorders of Back or Spine *

YES

NO

Emphysema, Tuberculosis,
Chronic Obstructive Pulmonary Disease *

YES

NO

Please provide details for any “Yes” answers for each of the questions listed below:

Within the last 5 years, has anyone enrolling for coverage been diagnosed as having or been treated for Human Immunodeficiency virus (HIV) infection, any other acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC) condition, significant weight loss, chrnic fatigue, diarrhea, night sweats or enlarged glands: *

YES

NO

(If above answer is yes) *

Are you or any dependent (whether enrolling for coverage or not) currently pregnant or anticipating surgery, or is anyone enrolling for coverage disabled, restricted or unable to perform the normal activities of daily living and self *

YES

NO

(If above answer is yes) *

During the past 5 years, have you or anyone enrolling for coverage had regular routine physical exams: *

YES

NO

(If above answer is yes) *

During the past 5 years, have you or anyone enrolling visited a doctor or had a medical condition for something other than a routine exam: *

YES

NO

(If above answer is yes) *

During the past 5 years, has anyone enrolling for coverage had surgery or been hospitalized: *

YES

NO

(If above answer is yes) *

Are you or any dependent enrolling for coverage currently taking medication? If so, please specify the medication(s) on the next page: *

YES

NO

(If above answer is yes) *

For anyone enrolling for coverage, is there any existing medical condition or problem (including any undiagnosed symptoms) that has not otherwise been disclosed on this enrollment form? If “yes” answer, provide details below: *

YES

NO

(If above answer is yes) *

SECTION 3 – EMPLOYEE STATEMENT AND SIGNATURE

I HEREBY: Request enrollment in the Group Health Plan (Plan) established and maintained by my employer (Employer) for its eligible employees and their eligible dependents; Represent that I am an eligible employee of the Employer; Represent that my statements and answers to the questions in this enrollment form are true and complete to the best of my knowledge and belief; and Authorize the Employer to deduct any required Plan contribution from my earnings.

I FURTHER ACKNOWLEDGE AND UNDERSTAND: This is not an insured benefit plan; All Plan benefits are self-funded (self-insured) by the Employer; The Employer is solely responsible for all benefit payments; Coverage is not effective until the Plan approves this enrollment form; Plan benefits are available only if a person is covered under, and all required contributions for such coverage have been received by, the Plan; If I have waived coverage for a dependent, I also waive all claims under the Plan for benefits for that dependent. A full description of the medical expense benefits under the Plan appears in the Summary Plan Description, which summarizes the official Plan Document; The agent submitting this enrollment lacks authority to change the enrollment form, approve Plan coverage, alter Plan terms, or adjust claims; IHP is not responsible for funding benefit payments; My statements and answers in this enrollment form will be the basis for approving Plan coverage and any material misrepresentation or omission may result in an increase in Plan contribution rates or termination of my coverage; Any person who, knowingly and with intent to defraud, submits an enrollment form, or files a claim, containing a materially false statement, or omitting materially false information, may be found guilty of fraud in a court of law.

SPECIAL ENROLLMENT RIGHTS: If you acquire a new dependent by marriage, birth, adoption or placement for adoption, he/she may be able to enroll without delay or penalty, if you request enrollment within 31 days (of the marriage, birth, adoption or placement for adoption); If you decline enrollment for any dependent (including your spouse) because of other health plan or group insurance coverage, and that dependent subsequently becomes ineligible for the other coverage (or the employer stops contributing towards that coverage), he/she may be able to enroll without delay or penalty, if you request enrollment within 31 days of ineligibility or termination of employer contributions; If you decline enrollment for any dependent (including your spouse) because of coverage under Medicaid or a State child health plan, and that dependent's coverage is subsequently terminated due to ineligibility, he/she may be able to enroll without delay or penalty, if you request enrollment within 60 days of the termination of coverage; If you decline enrollment for any dependent (including your spouse) and that dependent subsequently becomes eligible for a premium assistance subsidy from Medicaid or a State child health plan, he/she may be able to enroll without delay or penalty, if you request enrollment within 60 days of eligibility for the subsidy. To request special enrollment contact the Employer.

PERSONAL INFORMATION NOTICE: As required by law, this notice is intended to inform you that 1) Personal information may be collected from third parties; 2) Such information as well as other personal or privileged information collected by the health plan or its legal representative may be in certain instances, as prescribed by law, disclosed to other third parties without your prior authorization; 3) You have the right to access and correct the collected information; 4) Your right to access does not include any information which relates to and is collected in connection with, or in reasonable anticipation of, a claim or civil or criminal proceeding; 5) We will provide a more detailed notice of information practices upon request.

AUTHORIZATION FOR RELEASE OF INFORMATION: I authorize the disclosure of all nonpublic personal information and individually identifiable protected health information for me (and my dependent(s), if applicable), including but not limited to employment status, other health plan coverage, diagnosis, prognosis, medical treatment or care, and physical or mental conditions (including alcohol or drug dependency), by any physician, medical practitioner, hospital, other medical related facility, insurance company, employer or benefit plan having such information, to the health plan or its legal representative, agent or vendor, for the purpose of processing enrollment and claims. I acknowledge and agree that this authorization shall be valid for two (2) years; that I may revoke it in writing at any time; that I may request a copy of this authorization; that enrollment, but not the processing of claims, is conditioned on my signing this

authorization; that this authorization will be used as its own document, separate from the enrollment form; that a photocopy of this authorization shall be as valid as the original; that any documentation or information disclosed pursuant to this authorization may be re- disclosed and may no longer be covered by federal or state privacy laws; and that I have authority to act as the personal representative of my dependent(s) (if requesting dependent coverage).

Date *

Signature of Employee X *

clear

Electronic copies of this enrollment card submitted via facsimile, email, or other electronic means shall be deemed an original.