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					To speed enrollment process,
please be thorough and fill out all sections that apply.

Groups with 51 or more employees

Enrollment Application/Change/Cancellation Request
for Medical Coverage
To speed enrollment process, please be thorough and fill out all sections that apply.                      s Enroll     s Address Change
                                                                                                           s Cancel     s Name Change
  A. Employee Information                                                                                  s Change     Date of Change____ /___ /____
First Name                                        M.I.         Last Name                                   Social Security #/Employee ID #

Street Address                                    Apt. #       City                          County        State        Zip                 Country

Home Phone                                 Work Phone                                 How many hours do              E-mail Address     s   Home      s   Work
                                                                                      you work per week?
Marital s Single s Divorced Sex s M Birthdate          Physician*                                                  Physician’s ID No.       Are you a
Status s Married s Widowed         sF                                                                                                       current patient?
 B. Family InformationFemale
                    s                                                                                                                       s Yes s No

Dependents to be enrolled, cancelled, changed: (Attach sheet if necessary)
Check        Last Name             First Name M.I.                                                                  Physician*                         Are you
appropriate                                             Sex Birthdate     Relationship**                                                              a Current
             Dependent Social Security No.                                                            Student       Physician’s ID Number
box                                                                                                                                                   Patient?
s   Enroll                                                                                        s Yes s No
                                                                   M                                                                                  s   YES
s   Cancel                                                                                        School Name:
                                                                   F                                                                                  s   NO
s   Change   SS# |   |   |   |–|   |   |–|    |     |      |
s   Enroll                                                                                        s Yes s Noo
s   Cancel                                                         M                              School Name:                                        s   YES
                                                                   F                                                                                  s   NO
s   Change   SS# |   |   |   |–|   |   |–|    |     |      |
s   Enroll                                                                                        s Yes s Noo
                                                                   M                                                                                  s   YES
s   Cancel                                                                                        School Name:
                                                                   F                                                                                  s   NO
s   Change   SS# |   |   |   |–|   |   |–|    |     |      |
*IMPORTANT: Please use the UnitedHealthcare directory of providers to choose a Primary Physician (Primary Care), for yourself and each of your covered
dependents for UnitedHealthcare Select and Select Plus only. **For court ordered dependent, legal documentation must be attached. Please see employer
                                                          representative for more information about the qualifications for full-time student status. If
  C. Product Selection (check all that apply)             dependent does not reside with eligible employee, please provide address on separate sheet.
MEDICAL BENEFITS:                            DENTAL BENEFITS:                                 s I decline coverage for myself
s Employee Only Coverage                     s Employee Only Coverage                         s I decline coverage for my spouse
s Employee/Spouse Coverage
                                             s Employee/Spouse Coverage                       s I decline coverage for my children
s Employee/Children Coverage
                                             s Employee/Children Coverage                     Reason:      s Covered under another plan
s Employee/Spouse/Children Coverage
s No Medical Coverage                        s Employee/Spouse/Children Coverage                           s Other:______________________________

  (complete Section E)                       s No Dental Coverage                                                 ______________________________

OVERTURE PLAN DESIGN (Check one selection if your employer has offered an Overture Package.)
s UnitedHealthcare Overture Classic     s UnitedHealthcare Overture Performance          s UnitedHealthcare Overture Premier

 D. To Be Completed By Employer
Company Name                                      Group #              Plan      Medical _________ Reporting Medical _________ Department #
                                                                       Variation Dental __________ Code      Dental ___________
s New Enrollment/Additions: (Check one)                                    (attach
                                                                                         s   Cancellations:     Last Date of Employment ___ /___ /___
   Date of Hire ___ /___ /___ Requested Date of Coverage ___ /___ /___ COBRA                 Requested Effective Date of Cancellation ___ /___ /___
   s New Hire        s Status Change (PT to FT)                                              s Cancel all coverage
   s Return from Leave/Layoff                                                                s Cancel listed above – Section B
   s Birth      s Marriage     s Adoption (attach legal documentation)                       Reason: (check one)
   s Court ordered dependent (attach documentation)                                          s Death s Employee Terminated s Divorce
   s Other (describe) ________________________                                               s Moved out of service area
 s COBRA/Continuation start date _______ stop date________                                   s Dependent reached student/dependent max age
 s Annual Open Enrollment     Requested Effective Date of Enrollment ___ /___ /___           s Other (describe)______________________________

Product Selections – Check all that apply             Union s Non-union
                                                               s             s Salaried  s Hourly     s Active  s Retired/Date_______

s   UnitedHealthcare Choice +^             s UnitedHealthcare Choice Plus +^     DENTAL PLANS
s   UnitedHealthcare Select+^              s UnitedHealthcare Options^           s UnitedHealthcare Dental Managed Indemnity^
s UnitedHealthcare Managed Indemnity^ s UnitedHealthcare Options PPO 80/80^ s UnitedHealthcare Dental Options PPO^
s UnitedHealthcare Select Plus +^          s [UnitedHealthcare Rhapsody^]
s UnitedHealthcare Overture^ Package ______ (A-S)
+Provided by UnitedHealthcare of New York, Inc.
and UnitedHealthcare of Upstate New York, Inc.
^Provided by United HealthCare Insurance Company of New York

475-1693 12/01 NY KA Enrollment
                                                                                                           Applicant Name ________________________
ATTENTION EMPLOYER REPRESENTATIVE: To ensure accurate processing of application, 1) please review all sections and confirm employee
completed the appropriate information. 2) Complete section D. 3) Please provide your signature and today’s date.
                                                                                                                 Grp/Subgrp/Bnft Grp
Signature _____________________________________________________ Date ___________________________
                                                                                                                 Plan Variation
Employer Position__________________________________________ Phone Number________________________ Reporting Code/Branch

  E. Other Medical Coverage Information / Waiver      (This section must be completed)
Have you or your dependents had any other medical coverage in the last 12 months? s YES s NO Will this coverage be terminated? s YES s NO
Insurance Company Name (use extra paper if needed)                               Coverage Start Date   Coverage Stop Date      If Yes, Date
Coverage type: s Group Policy s Individual Policy s Medicare/Medicaid s Other________________________________________________
Is this coverage through your spouse’s     Name, date of birth and Social Security # of policy holder
employer? s YES s NO If yes, please
provide employer’s name

Employee’s relationship to policyholder         Names of family members with other continuing medical coverage (Including Medicare)

Medicare effective date      Reason for Medicare eligibility:                 Medicare Claim #
Parts A&B                    s Over 65 s Disabled s Kidney Disease

WAIVER       I decline to enroll for this coverage for myself, my spouse, and my dependent children due to:
              s Existence of other health coverage      s Spousal coverage     s Other Reason (Explain) _____________________________________
              Check one of the above boxes, then read and sign.
I understand that if I and/or my dependents, if any, waive coverage and desire to participate in the plan at a later date, coverage may be subject to
treatment as a late enrollee and may apply at next open enrollment period. I further understand that if I decline enrollment for myself or my dependents
(including my spouse) because of other health coverage, I may in the future be able to enroll myself or my dependents in this plan, provided that I request
enrollment within 30 days after such coverage ends. In addition, if a new dependent relationship forms as a result of marriage, birth, adoption, or
placement for adoption, I may be able to enroll myself and my dependent provided that I request enrollment within 30 days after such marriage, birth,
adoption, or placement for adoption. I have read and understand the “Important Information”located on the back of this form.

X Employee Signature__________________________________________________________
                              (only sign if you are waiving coverage)
                                                                                                         Date Signed_____________________________

 F. Medical Research Studies / Additional
    Products & Services
s   Please do not send me information regarding medical research studies.
s   Please do not send me information regarding additional products and/or services.
 Signature (Form must be signed)
I confirm that the information I have provided on this form is complete and accurate.
I understand that the health benefit plan that I have selected provides reimbursement for certain medical costs, which are more fully described in the
current Certificate of Coverage or Summary Plan Description. I understand there may be instances where treatment decisions made by my physician or
me or medical expenses which I have incurred may not be covered by my health benefit plan.
I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention health products or
services that might be valuable to me and otherwise as permitted by law. I understand that you may combine that information with other information so
that it is no longer individually identifiable and use it for commercial and other purposes.
I acknowledge that I have received the “Important Information” statement which is included on the back of this form.
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.

Date ___________ Employee Signature ________________________________________ Spouse Signature ______________________________
                                                                             (if possible) and applicable
        White - Health Plan Copy             Canary - Health Plan Copy               Pink - Employer Copy             Goldenrod - Employee Copy

475-1693 12/01 NY KA Enrollment
                                                                                               Applicant Name ________________________

In order to make choices about your health care coverage and treatment, we believe that it is important for you to understand how your
plan operates and how it may affect you. In an ever-changing environment, the information can never be complete and we urge you to
contact us if the information in your Summary Plan Description, Certificate of Coverage or other materials do not answer your questions.
Further information is available at 1-800-705-1691.
1. We do not provide medical services or make treatment decisions. We help finance and/or administer the health benefit plan in which
     you are enrolled. That means:
     • We make decisions about whether the health benefit plan you chose will reimburse you for care that you may receive.
     • We do not decide what care you need or will receive. You and your physician make those decisions.
2. We may enter into arrangements where another entity carries out some of our duties, but those entities must operate consistently
     with our commitment to your plan.
3. We may use individually identifiable information about you to identify for you (and you alone) procedures, products or services that you
     may find valuable.
4. We contract with networks of physicians and other providers. Our credentialing process confirms public information about the
     providers’ licenses and other credentials, but does not assure the quality of the services provided.
5. Physicians and other providers in our networks are independent contractors and are not our employees or agents. We do not control
     nor do we have a right to control your physician’s treatment or plan.
6. We may enter into agreements with your physician or other provider to share in the cost savings that our approach may generate.
     We encourage providers in our network to disclose the nature of those arrangements with you. If they do not, we encourage you to
     talk to your physician about these arrangements.
7. We encourage physicians to talk with you about medical care you or your physician think might be valuable.
8. We will use individually identifiable information about you as permitted by law, including in our operations and in our research. We
     will use anonymous data for commercial purposes including research.
9. Different providers in our network have agreed to be paid in different ways by us. Your provider may be paid each time s/he treats you
    ("fee for service"), or may be paid a set fee each month for each member whether or not the member actually receives services
10. These payment methods may include financial incentive agreements to pay some providers more ("bonuses") or less ("withholds")
    based on many factors: member satisfaction, quality of care, and control of costs and use of services among them.
11. If you desire additional information about how our primary care physicians or any other provider in our network are compensated,
    please call UnitedHealthcare at 800-705-1691 or write to: Network Relations Department, UnitedHealthcare, Two Penn Plaza, 7th Floor,
    New York, NY 10121.

 Statement of affirmation and authorization to obtain and disclose information in connection with eligibility for medical coverage.
I (we) request the indicated group medical coverage for myself and, if the plan provides, for my dependents, I authorize any required
premium contributions to be deducted from earnings.
I (we) authorize all providers of health services or supplies and any of their representatives to give the following to the HMO/insurance
company(ies): any available information about the medical history, condition or treatment of any person names in this request. I (we)
authorize the HMO/insurance company(ies) to use this information to determine eligibility for medical coverage and eligibility for benefits
under an existing policy.
I (we) also authorize the HMO/insurance company(ies) to give this information to its (their) representatives or to any other organization for
the reason notified above. I (we) agree that this authorization is valid for 30 months from the date of this form. I (we) know that I (we)
have the right to ask for and to receive a copy of this authorization.
I understand that the Certificate of Coverage or Summary Plan Description and other documents, notices and communications regarding
my health benefit plan may be transmitted electronically.
I (we) have not given the agent or any other persons any health information not included on the Request for Medical Coverage. I (we)
understand that the HMO/insurance company(ies) is not bound by any statements I (we) have made to any agent or to any other persons,
if those statements are not written or printed on this Request for Medical Coverage and any attachments.
I have a continuing obligation to report changes in health status (e.g. received medical advice, diagnosis, care or treatment) after I sign
the enrollment form and before receipt of my identification card.

Group Medical Insurance provided by or through:
UnitedHealthcare of New York, Inc.
UnitedHealthcare of Upstate New York, Inc.
United HealthCare Insurance Company of New York

475-1693 12/01 NY KA Enrollment
                                                                                        FLEXIBLE SPENDING ACCOUNTS
                                                                                        SPONSORED BY: Type Employer Name

                                                                                        We are pleased to offer you a money-saving benefit plan known
                                                                                        as a Flexible Spending Account or FSA.

                                                                                        This information describes what an FSA is, how it works and how
                                                                                        it can save you money. Enrollment is easy and you can save
                                                                                        significant dollars by participating.

                                                   GET AN INSTANT INCREASE IN PAY! ENROLL IN THE FSA PLAN TODAY.

                                               WHAT IS AN FSA?
                                               A Flexible Spending Account, or FSA, is an important part of your employer’s overall benefit
                                               package. Through the plan, you can set aside a portion of your earnings, tax-free, for everyday
1                                              expenses you may have with:
                                                  • Dependent day care expenses
                                                  • Out-of-pocket medical expenses including medical, dental, vision, over-the counter
                                                      medications, and prescription drug expenses

                                               When you choose to participate in this benefit program, it does not change your insurance benefits,
                                               it merely affects the way you pay your dependent day care and out-of-pocket medical expenses.
                                               You work hard for your money! Take advantage of the powerful benefits this plan has to offer. By
                                               participating in this plan you can increase your spendable income!

                                               HOW DOES IT WORK?
                                               When you enroll in the FSA plan, the amounts you elect are automatically deducted from your
                                               paycheck on a pre-tax basis. The money is held until you have a qualified expense. As you incur
                                               qualifying expenses during the year, you simply file a claim with UnitedHealthcare Benefit
                                               Services. There are many options available for submitting claims and all are quick and easy and
                                               provide fast turnaround. The claim is reviewed and tax-free reimbursements are made to you by
                                               check or direct deposit to a bank account of your choice. You
                                               can even view the status of your account online at anytime by
                                               visiting                                          MONEY-SAVING BENEFITS

                                               IS IT A GOOD DEAL?
                                               The money you set aside is never counted as income. That
                                               means it is not subject to federal income tax, Social Security,
                                               Medicare, and in most cases, state and local taxes. This              INCREASE YOUR TAKE-HOME PAY
                                               lowers your taxable income and increases your spendable
                                               income. Depending on your tax situation, you could save 27-          SAVE 27-43% ON YOUR EXPENSES -
                                               43% on expenses you would be paying anyway.                            SEE THE FOLLOWING PAGE FOR
                                                                                                                             SAVINGS EXAMPLE
                                               WHAT ABOUT MY INSURANCE PREMIUMS?
                                               Premiums as part of your employer’s qualifying group                USE TAX-FREE DOLLARS TO PAY FOR
                                               insurance plans will automatically be deducted on a pre-tax         EXPENSES YOU WOULD PAY ANYWAY
                                               basis thereby easily saving you money.
                                               WHAT EXPENSES QUALIFY?
                                               The IRS allows two separate categories for expenses to be included in the plan.

                                                  DEPENDENT DAY CARE EXPENSES

                                                  By enrolling in this category, you may save money on dependent day care expenses incurred so that you and your
                                                  spouse, if married, can work, look for work, or attend school on a full-time basis. You may set aside $5,000 per
                                                  year for work-related day care expenses for one or more dependents, or $2,500 if you are married and file separate
                                                  income tax returns.

                                                  Under certain circumstances, it may be beneficial for you to claim dependent day care expenses on your personal
                                                  income tax return rather than the FSA Plan. The best way to determine which is best for you is to compare the tax
                                                  credit you would receive on your personal income tax return with the tax savings from this benefit plan.
                                                  Individuals should consult a qualified tax advisor for additional assistance.

                                                  For a list of qualifying dependent day care expenses, please refer to the next page.

                                                  OUT-OF-POCKET MEDICAL EXPENSES

                                                  This category covers eligible medical, dental, vision, over-the-counter medications, and prescription drug
                                                  expenses. It is the most popular FSA category as most every household has these types of expenses. See the
                                                  sample list of qualifying expenses located on the next page for what types of expenses qualify.

                                                  Make sure to only include expenses that you expect to incur and can reasonably predict when you make your
                                                  election. You can use the worksheet on page 4 to help determine the amount.

                                                     Visit for a complete description of each account. While online, you can also view
                                                                       your account balances, claims, and reimbursement information.

                                               JUST HOW MUCH CAN I SAVE?
                                               You can save 27 - 43% on your qualifying expenses. The chart below shows an example in which
                                               the employee has both out-of-pocket medical and dependent day care expenses. The employee
                                               saves $1,493 annually with the FSA Plan.

                                                                                                                SAVINGS EXAMPLE

                                                                                                                  With FSA Plan          Without FSA Plan
                                                    Annual Pay                                                    $30,000                $30,000
                                                    Pre-tax contribution to FSA Plan
                                                      Health care expenses                                        $600                   $0
                                                      Dependent day care expenses                                 $4,800                 $0
                                                    Federal, State, and Social Security taxes*                    $6,802                 $8,295
                                                    After-tax dollars spent on eligible expenses
                                                      Health care expenses                                        $0                     $600
                                                      Dependent day care expenses                                 $0                     $4,800
                                                    Net spendable income                                          $17,798                $16,305

                                                    Tax savings with the FSA Plan                                 $1,493
                                                  * Assumes 15% federal tax, 5% state tax, and 7.65% Social Security tax.
                                                                                  QUALIFYING DEPENDENT DAY CARE EXPENSES

                                               •        Child care for dependents under the age of 13 that is           •     Custodial care for qualified tax dependents
                                                        necessary for you and your spouse to work or attend
                                                                                                                        •     Elder care including adult day care
                                                        school full-time
                                                                                                                   In divorce situations, only the custodial parent can claim
                                               •        Before and after school care
                                                                                                                   child care expenses. For a complete list of qualified
                                               •        Day camp if it is in lieu of day care                      dependent care expenses, please go to
                                               •        Au Pair/nanny dependent care

                                                                                  QUALIFYING OUT-OF-POCKET MEDICAL EXPENSES

                                                   •      Medical expenses:                                         •       Medical supplies:
                                                                    Deductibles                                                      Hearing aids and batteries
                                                                    Co-pays                                                          Diabetic supplies
                                                                    Office visits                                   •       Dental expenses:
                                                                    Routine exams or physicals                                       Exams
                                                                    Chiropractor                                                     Fillings
                                                   •      Over-the-counter drugs used to alleviate or treat                          Bridges
                                                          personal injuries or sicknesses:                                           Crowns
3                                                                   Pain relievers                                                   Dentures
                                                                    Allergy medications                                              Orthodontia
                                                                    Cold, cough and flu remedies                    For a list of qualified expenses, please go to
                                                                    Anti-itch drugs, creams and powders   

                                                   •      Vision expenses:
                                                                    Eyeglasses                                      NOTE: The Internal Revenue Service (IRS) can make
                                                                    Contact lenses and cleaning supplies            changes at any time and without notice. IRS changes have
                                                                    Eye exams                                       typically involved the eligibility of certain expenses and
                                                                    Corrective vision surgery                       circumstances that could allow you to make plan changes
                                                                                                                    after the year begins. Visit for the
                                                                                                                    most current information.

                                                   WHAT ELSE SHOULD I KNOW BEFORE I DECIDE IF THIS PLAN IS RIGHT FOR ME?
                                                   There are some important factors to consider before making            Your election amount will remain in effect for the plan year.
                                                   your decision.                                                        Changes in elections may only be made if you experience a
                                                                                                                         qualified change in status. The IRS defines a qualified change
                                                       The Summary Plan Description (SPD) details the amount             in status to include:
                                                       of medical expenses that can be deducted during your
                                                       plan year. Please refer to the SPD or contact your Human                   Change in your legal marital status
                                                       Resources Department for this important information.                       Change in the number of your tax dependents
                                                       You may participate in the plan even if you are not                        Your dependent satisfies (or ceases to satisfy)
                                                       enrolled in your employer’s medical or dental insurance                    eligibility requirements such as reaching the age limit
                                                       plans.                                                                     or getting married
                                                                                                                                  Change in residence for you or your spouse or
                                                       You may set aside pre-tax dollars to pay for your own                      dependent that affects eligibility of your benefits
                                                       qualifying expenses, as well as for your spouse and                        Change in employment for you or your spouse or
                                                       eligible dependents.                                                       dependent that affects eligibility of your benefits
                                                       You may enroll in the plan only during the open                       Contact your Human Resource Department for the
                                                       enrollment period or when you first become eligible.                  necessary forms in order to apply for a change in status.

                                                       Qualified expenses must be incurred during your period            If you participate in a Health Savings Account (HSA), you are
                                                       of coverage. Expenses are considered incurred on the              not eligible to participate in an out-of-pocket Medical Expense
                                                       date the service is provided, regardless of when it is            flexible Savings Account (FSA).
                                                       billed, charged or paid for.

                                                       If by chance you do not use up all of your funds by the
                                                       end of the plan year, you may have additional time in the
                                                       following year to incur qualifying expenses. Check with
                                                       your Human Resource Department or your SPD to see if
                                                       this option is available to you.
                                                     HOW DO I SIGN UP?
             STEP                              1     Enrolling in the plan is easy and can be done in 2 steps! Just estimate your qualifying expenses
                                                     and complete the enrollment process.

                                                ESTIMATE EXPENSES FOR YOURSELF AND YOUR DEPENDENT FAMILY MEMBERS
                                               GROUP INSURANCE PREMIUMS                                      DENTAL EXPENSES
                                                    Automatically deducted pre-tax from your paycheck        Deductibles
                                               DEPENDENT DAY CARE EXPENSES                                   Co-payments
                                                    January                                                  Routine exams
                                                    February                                                 Fillings
                                                    March                                                    Orthodontia
                                                    April                                                    Dentures
                                                    May                                                      Crowns, caps, bridges
                                                    June                                                     Root canals
                                                    July                                                     Other qualified dental expenses
                                                    September                                                SUBTOTAL
4                                                   November                                               TOTAL MEDICAL


                                                   TOTAL DEPENDENT DAY CARE*

                                               * Remember to account for holidays and vacation days when
                                                dependent day care will not be used.

                                               OUT-OF-POCKET MEDICAL EXPENSES
                                                    MEDICAL EXPENSES
                                                    Prescription drugs
                                                    Office visits
                                                    Routine exams
                                                    X-ray/lab fees
                                                                                                               Add up the subtotals you’ve calculated above, then
                                                    Hearing aids                                               divide by the number of paychecks you will receive
                                                                                                               during the plan year.
                                                    Psychiatrist/psychological visits
                                                    Over-the-counter drugs                                 TOTAL ALL EXPENSES
                                                    Other qualified medical expenses
                                                                                                           NUMBER OF PAYCHECKS ÷

                                                    VISION EXPENSES                                        AMOUNT PER PAYCHECK*
                                                    Eye exams
                                                                                                           *In most case, each category will be appear on your paycheck as
                                                    Prescription glasses                                   separate deductions.
                                                    Prescription contact lenses
                                                    Contact lens supplies
                                                    Laser eye surgery
                                                    Other qualified vision expenses

                                                              COMPLETE THE ENROLLMENT PROCESS
                          STEP                   2            You will receive enrollment materials from your employer each year or when you first
                                                              become eligible. Simply follow the instructions provided in the enrollment materials. It is
                                                              important to pay close attention to the enrollment deadlines. If you do not enroll by the
                                                              deadline, you will need to wait until the next year to enroll.

                                               HOW WILL I BE REIMBURSED FOR                                                          WHAT ABOUT THE PRIVACY OF MY
                                               QUALIFYING EXPENSES?                                                                  INFORMATION?
                                               After incurring qualifying expenses, simply                                           UnitedHealthcare Benefit Services places a high
                                               submit the expenses to UnitedHealthcare Benefit                                       priority on privacy and confidentiality. All
                                               Services (see How Do I File A Claim below).                                           processes and procedures are performed in strict
                                               You may be reimbursed by direct deposit to                                            compliance with HIPAA privacy rules and
                                               your bank account or by having a check mailed                                         regulations. You may obtain a copy of our
                                               to you. The frequency of reimbursement is                                             Privacy Statement at
                                               based on a schedule determined by your                                      
                                               employer. This information can be found in
                                               your Summary Plan Description (SPD).                                                  WHAT IF I HAVE ADDITIONAL QUESTIONS
                                                                                                                                     ABOUT MY CLAIMS OR ACCOUNT?
                                               HOW DO I OBTAIN CLAIM FORMS?                                                          You may obtain information in a number of ways:
                                               You may obtain claim forms at
                                      You may also call a                                                    ONLINE
                                               Customer Advocate at 877-797-7475 to have a                                                 You may obtain claim forms, information on
                                               form e-mailed, mailed or faxed to you.                                                      eligible expenses and detailed account,

                                                                                                                                           claims and payment information online at
                                               HOW DO I FILE A CLAIM?                                                            
                                               You may file claims online or by faxing or mailing.
                                               The choice is yours!                                                                        TOUCH-TONE PHONE
                                                                                                                                           Call 877-797-7475 24 hours a day, 7 days a
                                                   eCLAIM—ONLINE CLAIM FILING                                                              week. Follow the automated instructions to
                                                   Go to to file your                                                  your access account information.
                                                   claim online. This is the easiest method and
                                                   offers same day processing. Documentation                                               CUSTOMER ADVOCATE CENTER
                                                   can then be faxed or mailed to                                                          Call 877-797-7475 and press “0” to speak
                                                   UnitedHealthcare Benefit Services. The                                                  with a Customer Care representative.
                                                   reimbursement will then be made according                                               English and Spanish speaking
                                                   to the schedule set forth in your employer’s                                            representatives are available during normal
                                                   plan.                                                                                   business hours - 7:00a.m. to 7:00p.m.
                                                                                                                                           Central Time, Monday through Friday.
                                                   TRADITIONAL CLAIM FILING
                                                   Send or fax completed claim form, along
                                                   with documentation, to UnitedHealthcare
                                                   Benefit Services. Claims are processed
                                                   within two business days. The
                                                   reimbursement will then be made according
                                                   to a schedule determined by your employer.
                                                   This brochure provides a general overview of the FSA Plan. Please see your Summary Plan Description or your employer’s Plan Document for specific
                                                   information regarding the Plan. If any conflict arises between this brochure and the plan documents, the terms of the plan documents will prevail. This
                                                   information is subject to change at any time and without notice.

                                                   Insurance coverage provided by or through United HealthCare Insurance Company or its affiliates.

                                                                                                 UnitedHealthcare Benefit Services                  24 HOUR ACCESS: (877) 797-7475
                                                                                                 P.O. Box 1747                                      Toll-Free Fax for Claims: (800) 760-3727
                                                                                                 Brookfield, Wisconsin 53008-1747