NYSBA Health Plan Application by xiuliliaofz


									                                                     NYSBA Health Plan Application

1. Group/Sole Proprietor Information                                    5. Other Group Coverage (Groups 2+ Only)
Company Name____________________________________                        Name of Insurer____________________________________
Address___________________________________________                      Address __________________________________________
City______________________________________________                      Type of Coverage and Plan Design______________________
State ________ Zip___________ County________________                    _________________________________________________
SIC Code__________________________________________                      Effective Date of Policy______________________________
Contact Name______________________________________
Title______________________________________________                     Name of Insurer____________________________________
Phone No. (____)____________Fax No.(____)___________                    Address __________________________________________
Email_____________________________________________                      Type of Coverage and Plan Design______________________
Additional Office Locations___________________________                  _________________________________________________
_________________________________________________                       Effective Date of Policy______________________________
Type of Group:                                                          Was your Group terminated for non-payment of premium
          Sole Proprietor                                               within the last 12 months? _____Yes _____No
          Group Size 2-50
          Group Size 50+                                                6. Enrollment Class/Subgroup 1 (Groups 2+ Only)
Provide description of Group (this description must address type of
business or association, years in existence, present ownership)         Class Description (ex. All employees working 20+ hours/week) ____
_________________________________________________                       _________________________________________________
_________________________________________________                       Employer Contribution
                                                                                 Single: _________________________
2. Product Selection                                                             Parent & Child: __________________
*Please attach signed rate sheet for products selected.                          Husband & Wife: _________________
                                                                                 Family: _________________________
     NYSBA Premier PPO $25                                              New Hire Eligibility Policy:
        PA015 with $10/30/50 Unlimited Rx                                      Date of Hire
     NYSBA Plus PPO $30                                                        1st of month following date of hire
        PA002 with $10/30/50 Unlimited Rx                                      1st of month following ____ days of employment.
     NYSBA Comprehensive PPO $40                                        Indicate number of employees by type:
        PA008 with $10/30/50 Rx ($4,000 Annual Max)                              Single: _________________________
     NYSBA Basic EPO $40                                                         Parent & Child: __________________
        EA007 with $10 Generic Only Rx                                           Husband & Wife: _________________
                                                                                 Family: _________________________
Effective Date_______________________________
                                                                        6A. Enrollment Class/Subgroup 2 (Groups 2+ Only)
3. Group Administration (Groups 2+ Only)
                                                                        Class Description (ex. All employees working 20+ hours/week) ____
A. Total number of employees (full and part time)__________             _________________________________________________
B. Total number of full time employees (minimum of 20                   Employer Contribution
     hours/week or $15,000/year) ____________________                            Single: _________________________
C. Number of COBRA/State Continuation                                            Parent & Child: __________________
     participants___________________________________                             Husband & Wife: _________________
D. Number of eligible employees waiving coverage _________                       Family: _________________________
E. Total number eligible to enroll (B+C-D) _______________              New Hire Eligibility Policy:
                                                                               Date of Hire
4. NYSBA Membership Verification                                               1st of month following date of hire
                                                                               1st of month following ____ days of employment.
For Sole Proprietors:                                                   Indicate number of employees by type:
NYSBA Member Name: ______________________________                                Single: _________________________
NYSBA Member ID: ________________________________                                Parent & Child: __________________
                                                                                 Husband & Wife: _________________
For Groups with 2+ Attorneys:                                                    Family: _________________________
* Please use the NYSBA attorney census form to verify that your group
meets the NYSBA’s minimum membership requirement of 25%.

One International Plaza, Suite 400       Philadelphia, PA 19113                             NYSBA Health Plan Call Center: (888) 834-3664
                                                     NYSBA Health Plan Application
7. Billing Information                                                            9. Broker Information
Billing statement to be sent to:__________________________                        Name:               _________________________________
_________________________________________________                                 Firm Name:          USI Affinity
Address___________________________________________                                Address:            One International Plaza, Suite 400
City______________________________________________                                                    Philadelphia, PA 19113
State ________ Zip___________ County________________                              Phone No:           (888) 834-3664
Phone No. (____)____________Fax No.(____)___________
Email_____________________________________________                                10. Attachments
     Electronic Funds Transfer Authorization (Optional)                           The following must be attached to this master NYSBA Health
*Note: If account below is different from the binder check for this               Plan Application. Please see the New Group/Sole Proprietor
application, please attach a copy of cancelled check or savings deposit slip.     Application Checklist to ensure that all necessary documentation
Print Name (as it appears on account)_______________________                      has been provided.
Account Number ___________________________________                                Required:
Routing Number ___________________________________                                   Binder Check: Made Payable to USI Affinity
Account Type               Checking               Savings                            Individual Enrollment Form(s) for employee(s)
Print Name of Bank & Branch_________________________                                 Signed Rate Sheet
Bank & Branch Address ____________________________                                   Employee Census
_________________________________________________                                    Attorney NYSBA Membership Verification
                                                                                     Eligibility verification for employer and employees
I (we) hereby request and authorize you to effect a transfer each month on
the account (name and number shown above) for the payment of insurance            If Applicable:
premiums due during such month for the medical program elected. This                  Coverage Waiver Form(s)
authorization is to remain in effect until it is revoked by either of us in           Proof of prior coverage – i.e. carrier bill
writing. Until you receive such notice of revocation, I (we) agree that you
shall be fully protected in processing such transfers. I (we) agree that if any
such transfer is dishonored, the payment for insurance will be considered to
                                                                                  11. USI Affinity Representative Section
be in default pursuant to the terms of the policy. This authorization shall
be effective as of the date stated below.                                         The information provided in this section is true to the best of
                                                                                  my knowledge.
Signature of Premium Payor___________________________
Date_____________________________________________                                 Print Name____________________________________
8. Certification
                                                                                  To be completed by USI Affinity Enrollment Unit:
To the best of my knowledge, all the statements/responses in this                 Group #: _________________
application are true and complete. By signing this application, I certify that    Subgroup #:_______________
under penalty of perjury that all statements contained in this application are
true and accurate to the best of my knowledge. I further certify that I am
an officer or employee of this business and that I am dully authorized to
execute this application on behalf of the business.

Insurance Fraud Statement
I understand that any person who knowingly and with the 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 ($5,000)
and the stated value of the claim for such violation.

Print Name____________________________________

One International Plaza, Suite 400       Philadelphia, PA 19113                                        NYSBA Health Plan Call Center: (888) 834-3664

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