If signing for more than one child, please list the names of each child for whom you are signing:
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
For services received by a minor that under state law the minor may consent to treatment without parental or legal guardian consent:
___________________________________ ________________ _________________________________
Signature of Parent or Legal Guardian Date signed Name of Minor Child (please print)
for Minor Child (if minor received
treatment with knowledge of parent)
___________________________________ ________________ _________________________________
Signature of Minor Child (if minor may Date signed Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization)
___________________________________ ________________ _________________________________
Signature of Minor Child (if minor may Date signed Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization)
Uniform Employee Application
OCI 26-501 (R 6/2010)
Ins 8.50Ins 8.50 Underwriting restriction. In determining whether to issue or continue to provide coverage to a small employer, a small employer insurer may not consider the occupation of the employees of the small employer or the type of business in which the small employer is engaged. Ins 8.50 HistoryHistory: Cr. Register, October, 1992, No. 442, eff. 11-1-92. Ins 8.52Ins 8.52 Regulation of rates and rate changes. Ins 8.52(1)(1) Identification of the set of midpoint rates. Ins 8.52(1)(a)(a) Each small employer insurer shall identify a set of rates applicable to all combinations of case characteristics and benefit design characteristics that serves as the set of midpoint rates for policies issued to small employers. These rates shall be represented by any combination of rates and rating factors that satisfy the following: Ins 8.52(1)(a)1.1. All differences among rates in the set shall be in accordance with the insurer’s rate manual or rating procedures and shall be based on the actuarially determined values of the differences in case characteristics and benefit design characteristics. Ins 8.52(1)(a)2.2. The differences among the rates may not reflect any differences due to such factors as the claim experience, health status and duration of coverage of an individual policy or a collection of policies grouped according to anything other than case characteristics or benefit design. Ins 8.52(1)(b)(b) The set of midpoint rates identified in par. (a) shall apply during a specified period which shall not be less than one calendar month. Ins 8.52(2)(a)(a) For a new policy issued on or after March 15, 1992, the following table lists the maximum percent a rate may vary from the midpoint rate applicable to policies with the same case characteristics and benefit design characteristics according to the effective date of any rate applied to that policy: Ins 8.52(2)(b)(b) For a policy issued before March 15, 1992, an insurer shall comply with the rate variance restriction specified in par. (a) 2 no later than August 15, 1994. Ins 8.52(3)(3) Premium rate changes; documentation and restrictions. Ins 8.52(3)(a)(a) For the purpose of complying with s. 635.02 (2), Stats., and this subsection,“class of business” means a group of policies with the same or similar benefit design whose rates are based wholly or partly on their aggregate loss experience. Ins 8.52(3)(b)(b) For a policy renewed on or after March 15, 1993, an insurer shall maintain sufficient documentation so that each of the following distinct components can be identified: Ins 8.52(3)(b)1.1. The percentage change in the new business premium rate measured from the rating period in which the small employer was last rated to the current rating period or, in the case of a class of business for which the insurer is not issuing new policies, the corresponding change in the base premium rate.