2014 Underwriting Requirements for Individuals enrolling with. Health Republic Insurance
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1 2014 Underwriting Requirements for Individuals enrolling with Health Republic Insurance 1. Completed Health Republic Insurance Enrollment Form 2. Signed Health Republic Insurance Broker of Record Letter 3. Completed Attestation 4. Cancel Letter to terminate current insurance coverage (must be on company letterhead) Options for Submitting completed underwriting packets: Mail: Fax: Bene-Care Agency 2809 Wehrle Dr., Suite 6 [email protected] Williamsville, NY Attn: Underwriting Department Please choose only one option for submitting paperwork and do not send duplicates. To receive confirmation that we have received your paperwork when mailing or faxing, please include an address.
2 HEALTH INSURANCE ENROLLMENT FORM For coverage provided by Freelancers Health Service Corporation DBA Health Republic Insurance of New York APPLICANT INFORMATION Marital Status Single Married Domestic Partner Street Address INSURANCE INFORMATION Select a Plan: Home Phone ( ) - Apt Daytime Phone ( ) - Are you eligible for Medicare? City EssentialCare Bronze Plan EssentialCare Silver Plan EssentialCare Gold Plan inum Plan State Zip Code Plan Start Date: (MM/DD/YYYY) -Only Plan EssentialCare Gold Child-Only Plan EssentialCare Silver Child-Only Plan EssentialCare Platinum Child-Only Plan Silver Plan Gold Plan Platinum Plan 29 an Silver Plan Silver Plan 29 Will you be covered by any other health insurance in addition to the coverage you are electing now? If yes: Carrier Name Policy Number Effective Date (MM/DD/YYYY) Carrier Address Have you obtained stand-alone dental coverage that provides a pediatric dental essential health benefit through a New York Health Benefit Exchange-certified stand-alone dental plan offered outside the New York Health Benefit Exchange? If you answered yes, please provide the name of the company issuing the stand-alone dental coverage. If you answered no, Solistice Health Insurance Company, through an arrangement with Health Republic Insurance of New York, will provide you coverage of the required pediatric dental essential health benefit. Solstice will be informed of this enrollment via our online enrollment process, which sends members to their website to continue enrollment, and telephonically via a warm transfer from our enrollment staff to theirs. Each carrier will bill and collect premiums separately. FHSC EF001 Page 1
3 DEPENDENT INFORMATION Spouse/Domestic Partner: HEALTH INSURANCE ENROLLMENT FORM For coverage provided by Freelancers Health Service Corporation DBA Health Republic Insurance of New York Dependent 1: Dependent 2: Dependent 3: Relationship: Spouse Domestic Partner If you have additional dependents, please provide their information on a separate sheet of paper. Is this dependent eligible for Medicare? BROKER INFORMATION Broker: Broker Identification Number: Address: Broker Agency: FHSC EF001 Page 2
4 HEALTH INSURANCE ENROLLMENT FORM For coverage provided by Freelancers Health Service Corporation DBA Health Republic Insurance of New York ACKNOWLEDGEMENT (Read carefully before signing.) I, the Primary Proposed Insured (or Spouse signing below), by my signature set forth thereafter: agree to the following: (a) All statements and answers in this application are complete and true to the best of my knowledge and belief. (b) Insurance will take effect only if a certificate is issued based on this application and the first premium is paid in full. (c) No agent has the authority to waive any answer or otherwise modify this application or to bind the Company in any way by making any promise or representation which is not set out in writing in this application. 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Signature Print Name Date / / MM DD YYYY Please mail completed form to: Health Republic Insurance of New York PO Box Atlanta, GA FHSC EF001 Page 3
5 Health Republic Insurance of New York 30 Broad Street 34 th Floor New York, NY This is to notify you that effective (effective date), I, (subscriber name), have appointed Bene-Care Agency LLC, whose business address is 1260 Creek Street, Webster, NY as our sole insurance representative. This designation of Broker of Record will remain in effect until I notify Health Republic Insurance of New York in writing to the contrary. Sincerely, Signature Please print Date
6 ATTESTATION I attest that I am eligible to enroll in Health Republic Insurance of New York during the Special Election Period (SEP) as a result of the qualifying event noted below. Please mark the appropriate box indicating your qualifying event situation: Loss of health coverage from previous employer or insurance carrier Marriage or Domestic Partnership Birth/Adoption/Placement for Adoption/Placement in Foster Care Becoming a Citizen, National or Lawfully Present Individual American Indian/Alaskan Native Loss of health coverage due to Divorce/Annulment/Legal Separation Permanent Move No Longer Incarcerated Other Applicant Signature Date Broker Services Department 30 Broad Street, 34 th Floor New York, NY Tel newyork.healthrepublic.us HRINY_EN09_OffExcAttForm061714
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