If “Yes,” provide information as requested regarding the product, duration and frequency of use in section H below.
D. In the past 5 years has anyone named in this application been evaluated or treated for alcoholism or chemical dependency; or joined any organization for alcoholism or chemical dependency; or used illegal drugs or been advised by a health care professional to reduce the use of alcohol or illegal drugs?   [ ] Yes [ ] No
E. Is anyone named in this application now disabled, mentally incompetent or unable to perform normal work or age-related activities?   [ ] Yes [ ] No
If “Yes,” please identify name(s), health condition(s), date(s) of disability and name(s) and address(es) of the attending physician(s):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
F. Within the past 10 years, has anyone named in this application been counseled, consulted or treated for any of the following (please check all conditions that apply):
- See PDF for table PDF
- See PDF for table PDF
G. Within the last 5 years, has anyone named in this application to be covered by this insurance had any other injury, illness or treatment for any condition not already listed; been hospitalized or been scheduled for hospitalization; had surgery or had surgery scheduled; had a test or a test scheduled; or been recommended to have a test or surgery which was not performed for any reason not already mentioned in this application? We are not seeking the results of HIV Antibody test.   [ ] Yes [ ] No
H. In the space below please list and provide the complete details if you answered “Yes” above to any of the questions or conditions contained in sections A through F. (Attach additional pages as needed and sign the additional pages.)
- See PDF for table PDF
I. If anyone named in this application is taking medication or has had prescribed or recommended any medication during the period of time related to your answer (i.e. past 5 years, past 10 years, or currently taking), please list all those medications, dosages, and what medical condition is being treated or were treated by each medication in the space provided below. (Attach additional pages as needed and sign the additional pages.)
- See PDF for table PDF
- See PDF for table PDF
I understand that I am eligible to apply for group health insurance through my employer. I do NOT want, and hereby waive, group health insurance for (check the box that applies):
[ ] Waiving for myself   [ ] Waiving for my spouse   [ ] Waiving for my dependent child(ren)
[ ] Waiving for me, my spouse and my dependent child(ren)
I am waiving group health insurance because (check all that apply):
[ ]   I, the employee, am covered or will be covered under another plan that is not sponsored by my employer. I am not enrolled for coverage under the Health Insurance Risk-Sharing Plan (HIRSP). If currently covered, please attach a copy of your identification card for that plan.
[ ]   I, the employee, do not have a risk characteristic or other attribute that would be the sole cause for the small employer insurer to make a decision with respect to premiums or eligibility for a policy that is adverse to the small employer.
[ ]   My spouse is covered or will be covered under another plan that is not sponsored by this employer. My spouse is not enrolled for coverage under the Health Insurance Risk-Sharing Plan (HIRSP). If currently covered, please attach a copy of your spouse’s identification card for that plan.
[ ]   My dependent child(ren) is covered or will be covered under another plan that is not sponsored by my employer. My dependent child(ren) is not enrolled for coverage under the Health Insurance Risk Sharing Plan (HIRSP). If currently covered, please attach your identification card for that plan. Please list, below, the name(s) of the child(ren) for whom coverage is being waived.
[ ]   I am not enrolled under the Health Insurance Risk-Sharing Plan (HIRSP) and the annualized premium contribution to be paid by me on behalf of myself or my dependent spouse and child(ren) would exceed 10% of my annualized gross earnings from this employer.
[ ]   Other reason (Please provide a written reason for waiving coverage):
____________________________________________________________________________________________________
WAIVER: I certify that I have been given the opportunity to apply for group health insurance and decline to enroll as indicated above, on behalf of myself, my spouse and my dependent child(ren). I understand that by signing this waiver, I, my spouse, and my dependent child(ren) forfeit the right to coverage. I was not pressured, forced or unfairly induced by my employer, the agent or the insurer(s) into waiving or declining the group health insurance. If in the future I apply for coverage, I, my spouse, or any of my dependent child(ren) may be treated as a late enrollee and subject to postponement or an exclusion of coverage for preexisting conditions for a period of up to 18 months. This period may be offset by the time I, my spouse or my dependent child(ren) was covered under a qualified health plan.
I understand that if I am declining enrollment for myself, my spouse, or my dependent child(ren) because of other health insurance coverage, including Medicaid, I may in the future be able to enroll myself, my spouse, or my dependent child(ren) in this plan, provided that I request enrollment within 30 days after my other health coverage ends or 60 days after Medicaid ends. In addition, if I gain a dependent spouse or child(ren) as a result of marriage, birth, adoption, or placement for adoption, I understand that I may be able to enroll myself, my spouse and my dependent child(ren), provided that I request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. If I am declining enrollment for myself, my spouse or my dependent child(ren) because of coverage under Medicaid, I understand that if I, my spouse or my dependent child(ren) become eligible for group health plan premium assistance under Medicaid, I may be able to enroll myself, my spouse or my dependent child(ren), provided I request enrollment within 60 days of initial eligibility for the premium assistance. I understand that I can obtain enrollment information from my employer or small employer group health insurance carrier.
Signature of Employee: ______________________________________________ Date Signed: ____________________________