Form 5217ut - Utah Universal Small Employer Application

J. WAIVER OF COVERAGE

COMPLETE WHEN WAIVING COVERAGE FOR SELF AND/OR DEPENDENTS

Employer:

Employee Name: (Last)

(First)

(MI)

INDIVIDUALS WAIVING COVERAGE

Date of Coverage

Will

Name of Individual

Type of Coverage

MM/YYYY

Insurer and phone number

coverage

waiving coverage

(Check all that apply)

continue?

Start Date

End Date

Employee:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

Spouse / Domestic Partner:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

Dependent:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

Dependent:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

Dependent:

 Yes

 Group

 Individual

 Governmental

(mm/dd/yyyy) (mm/dd/yyyy)

 No

 Medical

 Dental

 Other

HEALTH STATEMENT

Pregnancy / Adoption: Is any individual waiving coverage pregnant or financially responsible for an unborn child? If currently pregnant,

YES

provide expected due date: ___________________.

(mm/dd/yyyy)

Do you anticipate complications or multiple births?

►

Have you had prior complications or multiple births?

►

IF “YES”, PROVIDE DETAILS IN THIS SECTION

Attach a separate sheet if necessary.

Diagnosis/Treatment date(s)

Explain diagnosis, illness, treatment received, testing, consultations, future

Physician, clinic, or hospital name. If known,

Name of Individual

Start Date

treatments, and remaining symptoms or problems

provide phone number or address.

MM /YYYY

(mm/dd/yyyy)

ACKNOWLEDGEMENT AND SIGNATURE

I acknowledge that I have had the opportunity to enroll, but do not wish to make application for those individual(s) listed above. In waiving coverage, I am aware that

waiving individuals (including myself, if I am waiving) may not enroll until my group’s anniversary, unless the waiving individual qualifies for a Special Enrollment

Period (SEP). If I have waived enrollment for myself or any of my dependents (including my spouse) because of other health care coverage or group health plan

coverage, I may in the future be qualified for a SEP and be able to enroll the waived individuals in this plan, provided I request enrollment within 30 days after the

other coverage of the individual(s) ends due to loss of eligibility or an employer’s ceasing to contribute toward that other coverage (within 60 days if the other

coverage was Medicaid or CHIP). In addition, if I have a new dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll

myself and my dependents, provided that I request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I further certify that all information completed on this form is true, correct and complete, and acknowledge my coverage is subject to cancellation or other action

permissible by law, if any completed information is found to be false or incorrect.

(mm/dd/yyyy)

Employee Signature______________________________________________________________________________________Date___________________________

Page 4 of 4

Utah Small Employer Health Insurance Application October 2010

Form 5217UT (Rev. 10/10)