Application For Enrollment Form (Page 4 of 4) in pdf

YES

12.

Have you or any applying family member ever smoked cigarettes?

Family Member

Packs/Day

Years Smoked

Quit? If “Yes”, what year?

YES

13.

Do you or any applying family member drink alcoholic beverages?

Family Member

Drinks/Week

Type

AUTHORIZATION

I authorize any physician, surgeon, practitioner, hospital, medical care institution, insurance company or other organization, institution, person

or employer that has any records, or knowledge of care, treatment or advice of me/or my dependents, to give such information to StayWell or

its representatives. This authorization or a photographic copy remains in effect as long as necessary to evaluate my application and/or

process claims for me and/or my covered dependents. A photographic copy of this authorization shall be as valid as the original.

AGREEMENT

I understand that StayWell has the right to reject my application as allowed by local or federal law and if so, I will be notified in writing and

StayWell is not obligated to disclose the reason for refusal. If StayWell rejects my application, under no circumstance will any benefits be

payable for any person listed on this application. By signing this Application for Enrollment (Part II) and returning it to StayWell, I am applying

for health benefits for myself and/or my dependents who are listed in this Application for Enrollment (Part II).

NOTICE

Approval of this Application for Enrollment (Part II) is subject to special exclusions, as StayWell may, in its exclusive judgment, deem

appropriate as conditions for enrollment by reason of the applicant’s physical condition or prior, current, or potential health condition, as

allowed by local or federal law. StayWell reserves the right to refuse membership to any such applicant by reason of any prior,

current, or potential health condition, and is not obligated to disclose the reason for refusal.

I hereby certify that the foregoing answers are true and complete and to the best of my knowledge. If any condition, disease or change in

health status occurs after I complete this Application for Enrollment (Part II), but before the effective date, I must immediately update this

Application for Enrollment (Part II) by sending a written explanation to StayWell Insurance, 430 West Soledad Avenue, Hagåtña, Guam

96910, Attention: Underwriting Department. If I fail to provide this updated information, or if I provide any incorrect or incomplete answer

on this Application for Enrollment (Part II) or in future correspondence concerning this Application for Enrollment (Part II), my coverage

and/or my dependents’ coverage may be terminated at any time. I further understand that, if I am applying without creditable coverage, pre-

existing medical conditions (known or unknown at the time of this Application and effective date of coverage), are excluded and that any

misrepresentation as to the presence of pre-existing impairment(s) or disease(s) or any medical conditions will void health care benefits.

I HAVE READ THE ABOVE CONDITIONS AND I CERTIFY THAT THE INFORMATION FURNISHED IS TRUE AND CORRECT TO THE

BEST OF MY KNOWLEDGE. I AM RESPONSIBLE FOR THE ACCURACY AND COMPLETENESS OF THIS APPLICATION.

All applicants 18 years old and over must sign below.

PRINT NAME OF APPLICANT

SIGNATURE OF APPLICANT OR LEGAL GUARDIAN

DATE

DATE OF BIRTH:

PRINT NAME OF APPLICANT’S SPOUSE

SIGNATURE OF APPLICANT’S SPOUSE

DATE

DATE OF BIRTH:

PRINT NAME OF FAMILY MEMBER AGE 18 AND OVER

SIGNATURE OF FAMILY MEMBER AGE 18 AND OVER

DATE

DATE OF BIRTH:

PRINT NAME OF FAMILY MEMBER AGE 18 AND OVER

SIGNATURE OF FAMILY MEMBER AGE 18 AND OVER

DATE

DATE OF BIRTH:

SW-APP PART II 02/12

Application For Enrollment Form Page 4

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