cbg CONFIDENT VISION ENROLLMENT KIT

Transcription

1 cbg CONIDENT VISION ENROLLENT KIT

2 cbg CONIDENT Vision Care Insurance Employer Application Company Name: Request Effective Date: Address: City: State: Zip Code: Phone Number: Contact Name: ax Number: E-ail Address of Contact: EPLOYER INORATION The undersigned applicant requests the Vision Care Insurance Benefits shown herein and provided by United Healthcare Insurance Company, and agrees to be bound by the terms and provisions of the Vision Care Insurance Policy. Total number of eligible persons: Total number of covered persons: ed Census: Employee Employee+Spouse Employee+Child(ren) amily Service requency Exam Lenses rames Co-pays 12 onths 12onths 24 onths $10 Exam $25 aterials Benefits* Network Out-of-Network Eye Examination 100% up to $40.00 Spectacle Lenses Single Vision 100% up to $40.00 Bifocal 100% up to $60.00 Trifocal 100% up to $80.00 Lenticular 100% up to $80.00 rames 100% up to $45.00 Elective Contact Lenses Covered-in-full contacts All other elective contacts 100% Necessary Contact Lenses 100% up to $ Non-Selection Contact Lenses: $ allowance: every 12 months cbg CONIDENT 5006 Lyndale Avenue South inneapolis, innesota

3 cbg CONIDENT Rates onthly Premium* Employee $7.08 Employee + Spouse $13.43 Employee + Child(ren) $14.11 amily $21.69 * Note: There is a $10 monthly administrative fee for CONIDENT stand-alone vision. Authorized Group Officer s Signature Printed Name of Group Officer Signature of Agent or Broker Printed Name of Agent or Broker Agency Name Agent s Telephone No.:Agent s ax No.: Agent s License No.: General Agency Name Send completed application to cbg 5006 Lyndale Avenue South inneapolis, N RAUD WARNING NOTICES: (Please review notice that applies in your state.) or applicants in Arkansas and Louisiana: Any person knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance, is guilty of a crime and may be subject to fines and confinement in prison. or applicants in Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds, shall be reported to the Colorado division of insurance within the Department of Regulatory Agencies. or applicants in District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the application. or applicants in lorida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. or applicants in Kentucky, New exico, Ohio and Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. or applicants in aine, Tennessee and Virginia: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. or applicants in New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. or applicants in all other states: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. cbg CONIDENT 5006 Lyndale Avenue South inneapolis, innesota

4 Voluntary Vision ment orm Group Voluntary Vision Coverage Provided by UHIC in partnership with Spectera Vision cbg CONIDENT SOCIAL SECURITY NUBER EPLOYEE ID NUBER (if different than SSN) DATE : / / LAST NAE IRST NAE I ADDRESS CITY STATE ZIP TELEPHONE NUBER HOE ( ) WORK ( ) APPLICANTS DATE O BIRTH EPLOYER OR GROUP NAE ale Single emale arried PLAN COVERAGE Employee Employee + Spouse (or Domestic Partner) Employee + Child(ren) amily irst Name Initial Last Name (if different) INORATION OR DEPENDENT COVERAGE Spouse & Unmarried Dependent Children Only (Include Date of Birth) Date of Birth (o/day/yr) Wife Relationship Husband Domestic Partner If Child is over 19, please indicate status and school *or court ordered dependent, legal documentation must be attached. Please see employer representative for more information about the qualifications for full-time student status. If dependent does not reside with eligible employee, please provide address on separate sheet. EPLOYER or GROUP AUTHORIZATION OR INTERNAL USE ONLY EECTIVE DATE SIGNATURE I understand that any coverage is limited by the benefits and exclusions of the Group Voluntary Vision Agreement. INIU ENROLLENT IS OR ONE YEAR CONIDENT S by cbg in partnership with Spectera Vision Plans are underwritten by United HealthCare Insurance Company, Hartford, Connecticut (except in New York), United HealthCare Insurance Company of New York; Hauppauge, New York (New York Only).

5 Provider Nomination orm* If you wish to nominate a particular ophthalmologist, optometrist or optician as a UnitedHealthcare Vision Care Provider, please complete this form and mail or fax it to: UnitedHealthcare Vision Attn: Network Development Liberty 6, Suite Old Dobbin Lane Columbia, D ax: Group Name: Your Name: Date: Name of Provider: Please check one of the following: Ophthalmologist Optometrist Optician Lasik Surgeon Street: _ City: State: Zip: Telephone: UnitedHealthcare Vision will make every attempt to contact nominated providers. Please allow 30 to 60 days from the time that UnitedHealthCare Vision receives this form for the potential provider to be contacted. It is our goal at UnitedHealthcare Vision to provide you and your eligible dependents with the highest-quality vision care plan available. Your time and assistance in completing this form is appreciated and will help us to provide you with extensive provider access. *Please note that nominating a provider does not necessarily guarantee that the provider will be a participant of UnitedHealthcare Vision s network. LCA-Vision owns and operates the Lasik panel. Acceptance into UnitedHealthcare Vision s network and LCA s network are independent of each other. A number of factors can affect a provider s participation. Some factors include but are not limited to geographic distribution of the existing network and population demographics. Thank you for submitting this Provider Nomination orm.