Matt
Patterson Insurance Agency, Inc.
222 E Hutchison, Suite 101
San Marcos Texas 78666
512 396-1234
UNICARE
Health Insurance Online Application
Required
fields are identified with an asterisk (*)
Where
field length is limited, please abbreviate.
1. Primary
Applicant Information:
Any
family member currently pregnant (whether or not listed
on the application) or in the process of adoption is not
eligible.
Last
Name*
First
Name*
MI
Primary
Applicant's
Social Security Number
Home
Address* (P.O. Box not acceptable)
Mailing
Address (if different) or P.O. Box In
Care Of
City*
State*
Zip Code*
County
City
State
Zip Code
Personal Mail Box (PMB)
Home
Phone Number*
Daytime
Phone Number
Fax
Number
(
)
(
)
(
)
E-mail
Address*
When
available, would you like to receive your member
notifications via e-mail?*
Yes
No
Billing
Type*
(Please
attach Summary Bill cover sheet)
Note:
Required even if Spouse not applying for coverage.
Marital
Status*
Spouse
Social
Security Number
Maiden
Name
of Applicant/Spouse
Has
any person listed on this application resided outside
the U.S. for the past six (6) consecutive months?*
Yes
No
If
yes, please explain:
Language
Choice (Optional):
If other, specify:
Ethnic
Code (Optional):
Required
fields are identified with an asterisk (*)
Where
field length is limited, please abbreviate.
3. Applicants
for Coverage
Insuring
Applicants*
Insure
all eligible applicants.
Insure
no one unless all are accepted for coverage.
Please
list all applicants applying for coverage. (youngest
to oldest)
If a listed family member's last name is different
than yours, please explain in the Additional Information
Appendix at the end of this application.
If you wish to cover children who are not yours
by birth, then you must do the following:
For adopted children, attach adoption papers to
the Signature Page, which you must print after
submitting your application.
For children under your legal guardianship, these
children must be on a separate on-line application.
Attach guardianship papers to the Signature Page
for separate on-line application or have the birth
parent sign the Signature Page.
Yourself
Relation*
Last
Name*
First
Name*
MI
Date
of Birth*
(mm/dd/yyyy)
Social
Security
Number
--
Must be accurate ---
Height,*
Weight*
Ft
In,
Lbs
4.
Other Coverage - Please answer all
of the following questions:
A.
Do
you currently have, or has anyone to be
insured had coverage in the last 18 months?*
Yes
No
If yes, please provide the following
information and attach Certificate of Creditable
Coverage from your prior health insurance
carrier.
Name
of Insured
Insurance
Carrier(s)
Effective
Date
(mm/dd/yyyy)
End
Date
(mm/dd/yyyy)
Please
attach the Certificate of Creditable Coverage
from your prior insurance carrier to the
confirmation statement that will be e-mailed
to you when your application is succesfully
submitted.
Do
you agree to discontinue your current coverage
if this application is accepted?
Yes
No
If
no, please explain:
If
the above question pertains to anyone else
on the application, please click the Add
button to add an additional row.
B.
Has
anyone on this application been insured
by UNICARE in the past 5 years?*
Yes
No
If
yes, please provide the following
information:
Name
of Former
UNICARE Insured
Plan/ID
No.
Group
No.
UNICARE
Plan
City/State
Date
Cancelled
(mm/dd/yyyy)
C.
Do
you have a UNICARE group coverage policy?
Yes
No
I
certify that my UNICARE Group Coverage terminated/will
terminate on: (mm/dd/yyyy)
I
do not wish to enroll in any available Conversion
Agreement. I understand that with the coverage
for which I am applying with this application
there may be a lapse in coverage. If accepted
with or without lapse in coverage, each
person may be subject to new waiting periods
and deductibles.
If
the above question pertains to anyone else
on the application, please click the Add
button to add an additional row.
D.
Has
anyone identified on this application been
declined, postponed, waiver applied, or
charged an extra premium for life, disability,
or health insurance, or had such insurance
rescinded?*
Yes
No
If
yes, please provide:
Name
of Insured
Insurance
Company
Brief
Explanation
If
the above question pertains to anyone else
on the application, please click the Add
button to add an additional row.
E.
Are
any persons applying for coverage on this
application eligible for Medicare benefits?*
Yes
No
If
yes, name of eligible person(s):
If
the above question pertains to anyone else
on the application, please click the Add
button to add an additional row.
F.
Has
anyone applying for coverage on this application
filed a claim for disability or Workers'
Compensation within the past 18 months?*
Yes
No
If
yes, please answer the following:
Name
of Eligible Person(s)
Effective
Date
(mm/dd/yyyy)
End
Date
(mm/dd/yyyy)
If
the above question pertains to anyone else
on the application, please click the Add
button to add an additional row.
6A.
Health History Questionnaire - ALL QUESTIONS MUST
BE ANSWERED OR THE APPLICATION MAY BE RETURNED AND/OR
REJECTED.
If
you answer "Yes" to any question in Section 6A,
you must give complete details in Section 6B.
Has
any person listed on this application had a clear,
distinct symptom that would cause an ordinarily
prudent person to seek advice or treatment, or had
treatment recommended, received treatment, or been
hospitalized for any of the following conditions
listed in numbers 1 through 24 within the last
10 years:
1.
Frequent
and/or severe headaches, migraines, seizures,
epilepsy, multiple sclerosis, or any other
neurological or central nervous system disorder(s)
Yes
No
2.
Dizziness,
weakness fainting, numbness/tingling, head
injury, paralysis, stroke, confusion, memory
loss, loss of consciousness, narcolepsy, or
any similar symptoms
Yes
No
3.
Chest
pain, high or low blood pressure, heart disease,
heart attack, heart murmur, palpitations,
pacemaker, or any other heart disorder or
condition
Yes
No
4.
Poor
circulation, blood clot, varicose veins, enlarged
lymph nodes, blood/bleeding disorder, anemia,
rheumatic fever, or any other circulatory
condition
Yes
No
5.
Allergies,
difficulty breathing, shortness of breath,
asthma, chronic cough, spitting/coughing up
blood, respiratory/lung infections, sinusitis,
bronchitis, pneumonia, pneumocystis carinii
pneumonia (PCP), tuberculosis, emphysema,
or any other respiratory disorder or condition
Yes
No
6.
Diseases
or problems of the nose, nosebleeds, polyps,
deviated nasal septum, excessive snoring,
or use of a sleep monitoring device
Yes
No
7.
Diseases
or problems of the mouth/gums, throat/swallowing,
tonsils, adenoids, jaw/chew problems or TMJ
Yes
No
8.
Gastric
reflux, ulcers, hernia, intestinal problems,
diverticulitis, colitis, diarrhea, rectal
problems/bleeding, polyps, hemorrhoids, or
any other digestive disorder or condition
Kidney/bladder/urinary
tract infections, stones, incontinence, blood
in urine or any other disease or disorders
of the kidneys or urinary system
Yes
No
11.
Bone,
joint and/or muscle pain, injury or disorder
of joint/tendon/ligament/disc, weakness of
back/spine/neck/joint, fracture, sprain/strain,
fibromyalgia, arthritis, gout, polio or any
other musculoskeletal disorder
Is
any applicant a candidate for, or a recipient
of an organ or bone marrow transplant?
Yes
No
16.
Skin
infections, cancer, melanoma, lesion, psoriasis,
keratosis, warts, ulcers, birthmarks, severe
burns, acne, fungal infections, Kaposi's sarcoma,
eczema, dermatitis, hyperhidrosis, herpes,
scars/keloids, cosmetic or reconstructive
surgery, or any other skin conditions
Yes
No
17.
Sexually
transmitted disease, such as herpes, genital
warts, etc.
Yes
No
18. Male
applicant(s) -
a)
Prostate, undescended testes, infertility,
low sperm count, impotence, sexual dysfunction,
or implant*
Yes
No
b)
Is any male listed on this application expecting
a child or in the process of adoption or surrogate
pregnancy with anyone, whether or not the
mother is listed on this application?*
Yes
No
19. Female
applicant(s) -
a)
Breast disorder/cyst, lump, fibroid tumors,
silicone injections, or implants*
Date
and result of last pelvic exam/Pap smear for
each female over 16:
Name*
Date
of last pelvic exam*
(mm/dd/yyyy)
Result*
Required
fields are identified with an asterisk (*)
Where
field length is limited, please abbreviate.
6B.
Professional Services
Please give COMPLETE details below for the questions
answered Yes to the questions in 6A. If necessary,
please use the Additional Information section
later in this application.
Name
of Family Member* (if identified
on physician records differently,
please note on Additional Information)
Name
of
Condition/Illness*
Date
of onset/treatment*
(mm/yyyy)
Still
under treatment?*
If
no, date ended
(mm/yyyy)
Yes
No
Treatment*
(i.e., x-ray, lab, surgical procedure)
Degree
of recovery/
result of exam*
Treatment
Results
Normal
Abnormal
Results
- abnormal (please explain)
Date
of Visit*
(mm/dd/yyyy)
Name
of Hospital, Clinic and/or person
providing care*
Phone Number*
Address*
Fax
Number
City*
State*
Zip*
Medication
(i.e. Lopressor)
Frequency
(i.e.daily)
Dosage
(i.e. 100mg)
Date
prescribed(mm/dd/yyyy)
Date
discontinued(mm/dd/yyyy)
If
the above question pertains to anyone else
on the application or to another condition
that you have, please click the Add button
to add an additional row.
6C.
Prescription Medications - List all medications
taken currently or within the last 12 months by
any family member listed on this application.
Family
Member*
Medication*
(i.e. Lopressor)
Dosage*
(i.e. 100mg)
Frequency*
(i.e.daily)
Illness
for which
medication is prescribed*
Name
of Physician or Hospital
Phone
Number
Date
prescribed*
(mm/dd/yyyy)
Date
discontinued*
(mm/dd/yyyy)
(
)
Address
Fax
Number
(
)
City
State
ZIP
Code
If
you need to add additional medication information,
please click the Add button.
6D.
Other Health Questions
1.
Has
any applicant ever smoked or used any tobacco
products - such as: cigarettes, pipe, cigar,
snuff or chewing tobacco?*
Yes
No
If
yes, please answer the following:
Family
Member*
Amount
per day*
Type
of product*
Date
discontinued*
(mm/dd/yyyy)
If
any other applicant has ever smoked
or used any tobacco products, please click
the Add button to add additional rows.
2.
Has
any applicant used illegal, controlled drugs,
or substances such as marijuana, cocaine,
methamphetamines in the last 10 years, or
been diagnosed as chemically or alcohol
dependent?*
Yes
No
If
yes, please answer the following:
Family
member*
Type
of product*
Date
Ended*
(mm/dd/yyyy)
If
any other applicant has used illegal,
controlled drugs, or substances in the last
10 years or been diagnosed as chemically
or alcohol dependent, please click the Add
button to add additional rows.
3.
Has
any applicant ever used any illegal or controlled
I.V. drug?*
Yes
No
If
yes, please answer the following:
Family
member*
Type
of product*
Date
Ended*
(mm/dd/yyyy)
If
any other applicant has used any
illegal or controlled I.V. drugs.
4.
Has any applicant consumed alcoholic beverages
in the last 6 months?*
Yes
No
If
yes, please answer the following:
Amount:
A drink is 12 oz. of beer, 6 oz. of wine,
or 1 oz. of liquor.
Family
member*
Amount
per day*
Amount
per week*
Amount
per month*
Type
of product*
If
any other applicant has consumed
any alcoholic beverages in the last 6 months,
please click the Add button to add additional
rows.
5.
Has
any applicant been advised to reduce alcohol
intake within the past 10 years?
Yes
No
If
yes, please answer the following:
Family
member*
Date
Ended*
(mm/dd/yyyy)
If
any other applicant has been advised
to reduce alcohol intake within the past
10 years.
Important:
It is important that you carefully read and
fully understand the following.
Please
check all boxes and select all effective dates
that are applicable to the plan for which you
are applying.
I,
the undersigned, understand that under the UNICARE
policy I am applying for, I will be entitled to
lesser benefits if I use a non-participating hospital,
physician, or other provider, than if I use a
UNICARE participating hospital, physician, or
other provider.
Effective
Date
If you currently have health coverage, we strongly
recommend that you maintain your current coverage,
and allow us to assign your effective date FOLLOWING
APPROVAL. If, however, you would like to request
a specific effective date, we strongly recommend
that you allow 60 - 75 days for underwriting.
This will help ensure that your application is
processed before you surrender your present insurance,
and will also prevent you from being required
to pay for two policies.
I
request that UNICARE assign my effective
date if my application is approved. My effective
date will be assigned as either the 1st
or the 15th of the month following the approval
date of my application.
If
UNICARE approves my application, please
assign an effective date of the
of the month following approval.
If
UNICARE approves my application, please
assign an effective date of the
of
.
This date must be after the signature date
but not greater than 75 days from the signature
date on this application.
REQUESTING
AN EFFECTIVE DATE DOES NOT GUARANTEE UNDERWRITING
TO BE COMPLETED BEFORE THE DATE REQUESTED. I UNDERSTAND
THAT IF I SELECT AN EFFECTIVE DATE, ONLY UNICARE
CAN CHANGE THIS DATE, HOWEVER, UNICARE CANNOT
CHANGE THIS DATE UNDER ANY CIRCUMSTANCES ONCE
THE PLANS IS ISSUED.
Billing
Date
UNICARE premiums are due on the 1st of each month.
Insureds with a mid-month effective date will
be billed on a pro-rated basis to bring future
due dates to the first of a month.
In
order to continue, you must review and agree to
the plan information by clicking on the links
below. These links will open a new browser window.
Once you have reviewed all the links, please return
to this page to continue your application.
Check
Number of months
premium Amount of
initial premium*
1 month 3 months $ .
8B. Billing Type
Monthly Billing (Available with Monthly Checking Account
Deduction).
1. Submit the one (1) month premium.
2. Complete section 8C, Monthly Checking Account Deduction
Authorization.
3. If your application is approved, the premium for
all products selected, including dental and/or life,
will be deducted from your checking account on the first
of the month ONLY.
Quarterly Billing - Submit the three (3) month premium.
Please note: First payment will be credited to approved
applicants only.
Attach a check for one(1) month's premium above where
indicated. If the account listed below is a joint account,
both account holders' signatures are required. Unicare
must be notified of any changes to your bank account
no later than the 20th of the month preceding the change.
AUTHORIZATION: As a convenience to me, I request and
authorize you to pay and charge to my account checks
drawn on that account by and payable to the order of
UNICARE provided there are sufficient collected funds
in said account to pay the same upon presentation. I
agree that your rights with respect to each debit will
be the same as if it were a check drawn on you and signed
personally by me. I authorize UNICARE to initiate debits
(and/or corrections to previous debits) from my account
with the financial institution indicated for payment
of my UNICARE premium. This authority is to remain in
effect until revoked by me in writing, and until you
actually receive such notice, I agree that you shall
be fully protected in honoring any such debit. I further
agree that if any such debit be dishonored, whether
with or without cause and whether intentionally or inadvertently,
you shall be under no liability whatsoever even though
such dishonor results in forfeiture of insurance.
NOTE: Should your withdrawal not be honored by your
bank, you will automatically be removed from Monthly
Checking Account Deduction and be billed quarterly.
After 12 months, you may re-apply for the monthly checking
account deduction option.
You will incur a $25 service charge for any withdrawal
not honored.
Applicant Name Applicant's Social Security No. Name
on Checking Account*
Name of Bank/Financial Institution* Address* City* State*
Zip Code*
Checking Account Number* Bank Routing No. Federal Credit
Union Routing No.
UNICARE must be notified of any changes to your bank
account no later than the 20th of the month preceding
the change.
Electronically
Review and Sign Your Application
Review
the information below and complete the required
fields in the Agreement and Signature section
below.
Click
the "I AGREE" button.
Once
you have successfully submitted your application,
a copy will be e-mailed to you as confirmation.
Please download and print your completed application
form the confirmation e-mail and retain it
for your records.
AGREEMENT
AND SIGNATURE
Agreement
(all applicants):
I,
the undersigned, understand that under the UNICARE
plan for which I am applying, I will be entitled
to lesser benefits if I use a non-participating
Hospital, Physician, or other provider, than if
I use a UNICARE participating Hospital, Physician,
or other provider.
I, the undersigned, agree to the following:
I
understand and agree to apy a non-refundable
application fee of $25 to be paid on a separate
check or through a separate credit card deduction
and to pay the premium amount required with
this application. If my application is denied,
UNICARE will return only the prmium payment.
If my application is accepted, theis premium
amount will be applied to the premium charges.
If
my application for UNICARE coverage is accepted
as applied for, the coverage date will be
as specified above, but I agree to have no
coverage under this application until I am
notified in writing by UNICARE that my application
is approved.
I
understand that UNICARE has the right to deny
my application, and if it does so, I will
be notified in writing, and the premium I
submitted will be returned.
MINOR
CHILDREN: I represent that I have made
such investigations as are necessary to assure
the truth and accuracy of all statements made
in this application regarding minor children.
CONCERNING
DEPENDENTS AGE 18 AND OVER: I represent
that my dependents age 18 and over (1) have
read this application, and have provided such
full and accurate information necessary to
complete this application, (2) I have discussed
all provisions of this application, especially
Sections 6A, 6B, 6C and 6D with them, and
(3) all information contained in this application
regarding them is complete and accurate.
I
understand and agree that if UNICARE rejects
my application, under no circumstances will
any benefits be payable for any person listed
on this application. Receipt of money, cashing
of my check or charging my credit card by
UNICARE does not constitute approval of my
application or create UNICARE coverage.
If
I am accepted, this application will become
part of the agreement between UNICARE and
myself.
UNICARE
may request additional information, and this
may delay processing of this application.
If the health care provider charges a fee
for these services, UNICARE will determine
payment, and I will be responsible for any
difference.
The
selling agent has no authority to promise
my coverage or to modify UNICARE underwriting
policy or terms of any UNICARE coverage.
I
have personally read and completed this application.
Nothing has been left off regarding the past
or present health of anyone listed on this
application. I understand that no one listed
is eligible for benefits if any information
on this application is false, incomplete,
or omitted. UNICARE may void all coverage
from the original effective date of the agreement
for such misstatements or omissions.
If a family member is a minor, I accept full
legal and financial responsibility for the
coverage and information provided on this
application. . PLEASE NOTE: If the listed minor dependent
does not reside with the applicant purchasing
this plan, the custodial parent or guardian
must complete the Health History Section and
sign the Conditions of Application accepting
legal responsibility for full and complete
disclosure of the minor applicant, including
any history of substance abuse. Also, if the
responsible adult is not the natural parent,
please submit court papers authorizing guardianship.
My
UNICARE agent may receive copies of any correspondence
about my medical history when correspondence
is required.
Authorization:
authorize any health care facility, physician,
surgeon, counselor, therapist or insurance company
to provide UNICARE, its agents, or employees,
including my UNICARE agent or broker, all information,
pertaining to me or any of my dependents who are
also applying for coverage, regarding past or
present medical conditions, any examination or
treatment, including treatment for alcohol abuse,
substance abuse, mental or emotional disorders,
AIDS (Acquired Immune Deficiency Syndrome), ARC
(AIDS Related Complex), and to any illness, injury,
or condition that I or my dependents have had
at any time in the past or future up until the
expiration of this Authorization. I understand
this information is collected in connection with
the evaluation and processing of any application
for coverage or change in benefits, or to determine
eligibility for benefits. The Authorization is
valid from the date listed below for a period
not longer than two (2) years. A photocopy of
this Authorization is as valid as the original.
My authorized representative, UNICARE agent, or
I am entitled to receive a copy of this form.
I understand and agree to all Conditions of
Application (Section 7). I understand that coverage
is subject to the provisions in the Conditional
Receipt (Section 11). I have read and understand
this application in its entirety I have received
a written plan description .
Optional
Monthly Bank Draft Authorization:
As
a convenience to me, I request and authorize you
to pay and charge to my account checks drawn on
that account by and payable to the order of UNICARE
provided there are sufficient collected funds
in said account to pay the same upon presentation.
I agree that your rights in respect to each such
debit shall be the same as if it were a check
drawn on you and signed personally by me. I authorize
UNICARE to initiate debits (and/or corrections
to previous debits) from my account with the financial
institution indicated for payment of my UNICARE
dues. This authority is to remain in effect until
revoked by me in writing, and until you actually
receive such notice, I agree that you shall be
fully protected in honoring any such debit. I
further agree that if any such debit be dishonored,
whether with or without cause and whether intentionally
or inadvertently, you shall be under no liability
whatsoever even though such dishonor results in
forfeiture of insurance. NOTE: Should your withdrawal
not be honored by your bank, you will automatically
be removed from Monthly Checking Account Deduction
and be billed quarterly. After 12 months, you
may re-apply for the monthly checking account
deduction option. You may incur a $25 service
charge for any withdrawal not honored.
Notice
to Applicant Regarding Replacement of Accident
and Sickness Insurance:
Last
Name
First
Name
MI
Social
Security No.
Policy
No.
Applicant:
PLEASE
NOTE:
This form must be completed, signed and submitted
to UNICARE along with your completed application.
Please keep the second copy of this “Notice”
for your files.
Will
this insurance replace any other accident and
sickness insurance presently in force?
Yes
No
If
yes, please supply the name of the other carrier:
and read the following information and sign
below.
According to your application, you intend to
lapse or otherwise terminate existing accident
and sickness insurance and replace it with a
policy to be issued by UNICARE Life & Health
Insurance Company. For your own information
and protection, you should be aware of and seriously
consider certain facts which may affect the
insurance protection available to you under
the new policy.
Health
conditions which you may presently have may
not be immediately or fully covered under
the new policy. This could result in denial
or delay of a claim for benefits under the
new policy, whereas a similar claim might
have been payable under your present policy.
You
may wish to secure the advice of your present
insurer or its agent regarding the proposed
replacement of your present policy. This is
not only your right, but it is also in your
best interest to make sure you understand
all the relevant factors involved in replacing
your present coverage.
If,
after due consideration, you still wish to
terminate your present policy and replace
it with new coverage, be certain to truthfully
and completely answer all questions on the
application concerning your medical/health
history. Failure to include all material medical
information on any application may provide
a basis for the company to deny any future
claims and to refund your premium as though
your policy had never been in force. After
the application has been completed and before
you sign it, re-read it carefully to be certain
that all information has been properly recorded.
The
above “Notice to Applicant” was delivered
to me on July 18, 2003
Any
person who, with intent to defraud or knowing
that he is facilitating a fraud against an insurer,
submits an application containing a false, incomplete
or deceptive statement may be guilty of insurance
fraud.
BY
CHECKING THE BOXES AND ENTERING MY NAME BELOW
I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN
THIS APPLICATION AND WARRANT THAT ALL OF THE INFORMATION
I HAVE PROVIDED IS TRUE, COMPLETE, AND ACCURATE.
Electronic Signature
Acknowledgement
I
understand that by applying for coverage
I am agreeing to the items under Agreement
above.
I
understand I am authorizing UNICARE to obtain
or release Medical Information as explained
under Authorization
above.
I
agree to provide an original (non-electronic)
signature if necessary to authorize the
release of medical information should it
be required in the future.
I
understand I am authorizing UNICARE to debit
my checking account for ongoing monthly
premiums as explained under Monthly
Bank Draft Authorization above.
I
agree to the terms listed in the Notice
to Applicant Regarding Replacement of Accident
and Sickness Insurance above and I acknowledge
receipt of this notice.
Please
type your name in the spaces below to electronically
sign your application:
First
Name
MI
Last
Name
(Parent
or Guardian if under 18 years of age)
Please
re-type your name in the spaces below to
confirm your electronic signature:
First
Name
MI
Last
Name
Please
type your city and state below:
City
State
On:
July 18, 2003.
I
Agree. Clicking the "I Agree" button below indicates
that you have reviewed your application and agree
with the statements in the Agreement and Signature
section shown above.
I
Disagree. If you do not agree with the statements
in the Agreement and Signature section shown above,
click the "I Disagree" button below. You will
not be able to apply online. If you wish to complete
a paper application instead, please click here.
UNICARE
Health Insurance Online Application
