Individual Policy Application


Instructions

Please complete all applicable areas of this application. WPS/Delta Dental of Wisconsin/WPS Health Plan, Inc. d/b/a Arise Health Plan ("Insurer") does NOT guarantee approval of this application for any person, or issuance of a policy. If you do not understand any questions on this application, please contact your Agent or Individual Sales Representative.

IMPORTANT!

1. Required fields are marked with an asterisk(*). Delays in processing will occur if values are not entered.
2. Do not use the browser back/forward buttons. Your data will not be saved.
3. Open enrollment is now closed. In order to enroll for coverage you must have a qualifying special enrollment event. Click here to see what documentation is required.

Form Number: 25062-051-1601


1. Information About You (Primary Applicant)

 


WPS and Arise are committed to support an Eco-friendly environment. The communications you receive from us will be available on our Member Portals.

2. Information About Your Family (if enrolling dependents, please complete this section)

Spouse Information

Anyone eligible for Medicare cannot be covered by this policy. Please use the Clear button to remove anyone covered by Medicare.
Last Name * First Name * Middle Initial Birth Date * Gender * Social Security # * Currently Eligible
for Medicare? *
 
Clear

Dependent Information

  Last Name * First Name * Middle Initial  Birth Date * Gender * Social
Security # *
Relationship
to Applicant *
Currently Eligible for Medicare? *  
1. Clear
2. Clear
3. Clear
4. Clear
5. Clear
6. Clear
7. Clear

3. Information on Eligibility



If yes, please list which applicants:

4. Type of Coverage and Benefits Plan

A. Types of Coverage and Benefits Plan - Please refer to your policy for any non-participating provider benefits. You can select each Plan Name Selection to display a Summary of Benefits and Coverage for that plan.

1. Standard Plans- Deductibles and out-of-pocket maximums listed below are for individuals. Family deductibles and out-of-pocket maximum are two times the individual. *

Selection Metal Tiers
and Preventive
Tier
Deductible Coinsurance
(amount you pay)
Out-of-
Pocket
Limit
Convenient
Care
Clinic Copay
PCP
Copay
Specialist
Copay
ER
Copay
Free
PCP
Visits
Prescription Plan
Generic/Preferred/Non-
Preferred/Specialty
Arise HMO Gold $1,500 20% $3,250 $10 $25 $50 $200 3 $0/$20/$50/$75/25% to $500
WPS PPO Gold $2,000 20% $5,000 $10 $25 $50 $200 3 $0/$15/$40/$65/25% to $500
WPS PPO Gold $3,000 0% $4,000 $10 $25 $50 $200 3 $0/$15/$40/$65/25% to $500
WPS PPO Silver $3,700 30% $6,850 $10 $30 $60 $250 3 $0/$20/$50/$75/25% to $500
Arise HMO
Arise POS
Silver $4,000 30% $6,850 $10 $30 $60 $250 3 $0/$20/$50/$75/25% to $500
WPS PPO Silver $4,500 10% $6,850 $10 $30 $60 $250 3 $0/$20/$50/$75/25% to $500
Arise HMO Silver $5,000 20% $6,850 $10 $30 $60 $250 3 $0/$20/$50/$75/25% to $500
WPS PPO Silver $6,000 0% $6,850 $10 $30 $60 $250 3 $0/$20/$50/$75/25% to $500
Arise HMO Silver $6,000 10% $6,850 $10 $30 $60 $250 3 $0/$20/$50/$75/25% to $500
Arise HMO
Arise POS
Silver $6,850 0% $6,850 $10 $30 $60 $250 3 $0/$20/$50/$75/25% to $500
WPS PPO Bronze $5,550 30% $6,850 D/C D/C D/C D/C 3 D/C
WPS PPO Bronze $6,000 20% $6,850 D/C D/C D/C D/C 3 D/C
Arise HMO Catastrophic* $6,850 0% $6,850 D/C D/C D/C D/C 3 D/C
WPS PPO Catastrophic* $6,850 0% $6,850 D/C D/C D/C D/C 3 D/C


2. HSA - Qualified HDHP Plans- Deductibles and out-of-pocket maximums listed below are for individual coverage. Family deductibles and out-of-pocket maximums are two times the individual. If you are applying for family coverage, the family deductible must be met before any benefits are paid. *

Selection Metal Tiers
and Preventive
Tier
Deductible Coinsurance
(amount you pay)
Out-of-
Pocket
Limit
Convenient
Care
Clinic Copay
PCP
Copay
Specialist
Copay
ER
Copay
Free
PCP
Visits
Prescription Plan
Generic/Preferred/Non-
Preferred/Specialty
Arise HMO
Arise POS
WPS HDHP
Silver $2,600 20% $4,000 D/C D/C D/C D/C 0 D/C
Arise HMO
WPS HDHP
Silver $3,500 0% $3,500 D/C D/C D/C D/C 0 D/C
WPS HDHP Bronze $5,000 20% $6,450 D/C D/C D/C D/C 0 D/C
Arise HMO
Arise POS
WPS HDHP
Bronze $5,500 20% $6,450 D/C D/C D/C D/C 0 D/C
Arise HMO
WPS HDHP
Bronze $6,450 0% $6,450 D/C D/C D/C D/C 0 D/C

D/C = Deductible and Coinsurance
PCP = Primary Care Physician
* Applies only to person under age 30 or have hardship exemption from the Federally Facilitated Marketplace.




B. Coverage Selection

Please choose the type of coverage you are applying for: *




C. Dental Benefit Plan

The dental plan is only available if you select one of the health plans shown above.


If any person applying for coverage has other dental coverage that is not cancelling and will not be replaced, you are not eligible for the dental plan coverage.

4. Type of Coverage and Benefits Plan (Cont.)

D. Primary Care Physicians - Arise Health Plan Only

If you are applying for coverage through Arise Health Plan, please select a Primary Care Physician (PCP) for yourself, your spouse and each dependent who is applying for coverage. If you do not know your Primary Care Provider, please enter "None."


  Last Name First Name Middle Initial Primary Care Physician *

5. Information About Other Medical Coverage

A. Other Coverage


B. Other Coverage Information

If you answered "Yes" to A. above, please provide the following information:


Name Current Health Carrier Policy or Group # Effective Date Termination Date Will coverage terminate
upon approval of this policy?
 
Clear
Clear
Clear
Clear
Clear
Clear
Clear
Clear
Clear

6. Policy Effective Date (If this application is approved by Insurer, the policy effective date is determined only by the Insurer)

Please indicate your requested effective date. Please note, the effective date can be no later than 60 days from the date of application.

 

 

The Policy Effective Date will be determined by the Insurer, subject to any applicable law or policy provisions.

7. Your Premium Payment Options (Business checks and/or accounts cannot be used for premium payment)

We send a premium notice directly to your home. You return payment to Insurer by the premium due date.



Information about other payment options including automatic withdrawal and credit/debit card will be included in your first premium notice.

8. Certification/Understanding Notice

CERTIFICATION: I represent and certify all of the following: * no answer or information in this application was provided by the agent or anyone else (except for information provided by other family members); * such representations are true, accurate, and complete to the best of my knowledge.

UNDERSTANDING: I understand: the representations I make, together with any supplemental representations that I make, shall be the basis for the Insurer to issue any coverage; * that no agent has the authority to waive an answer to any question, pass on insurability, make or alter any contract, or waive or alter any of the Insurer's other rights or requirements; * that no coverage will be effective unless and until the date specified by the Insurer after this application has been approved by the Insurer; * any misrepresentation contained herein may be used to reduce or deny a claim, or to rescind and void coverage and the policy within the contestable period, if such misrepresentation materially affects the Insurer's acceptance of the risk, including approving any person for coverage.

I understand that the Insurer has no liability for anything the agent said or failed to say before, during or after the application process, that's not subsequently confirmed in writing by an authorized officer of the Insurer, including, but not limited to, answers given by the agent in response to questions asked by myself, my spouse or my dependent(s). Furthermore, I understand that the Insurer is not liable for any statement, representation, or other information provided to myself, my spouse or my dependent(s) that isn't expressly contained in a written document provided to them and signed by an authorized officer of the Insurer.

I understand that the insurer fully complies with the regulations and orders regarding doing business with foreign countries or foreign nationals listed on the Office of Foreign Assets Control's Specially Designated Nationals and Blocked Persons (SDN) list. Therefore, the insurer may rescind and void any coverage if it determines that you, your spouse or any named dependent are either listed on the SDN list or associated with an entity listed on the SDN list.

I understand and acknowledge that any person who, with intent to defraud or knowledge that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false and deceptive statement is committing a fraudulent act, which is a crime. I further understand and acknowledge that in some states, any person who, for the purpose of misleading an insurer or other person, conceals significant information from an application or claim is committing a fraudulent act.

NOTICE TO APPLICANT REGARDING REPLACEMENT OF ACCIDENT AND SICKNESS INSURANCE

IF YOU ARE REPLACING OTHER INDIVIDUAL OR GROUP HEALTH COVERAGE, PLEASE READ THIS SECTION.

According to your application or the information furnished by you, you intend to lapse or otherwise terminate your present policy and replace it with a policy to be issued by the Insurer. For your own information and protection, certain facts shown below should be pointed out to you. If the Insurer approves your application for coverage and issues a policy, you should consider these facts before you lapse or terminate your present policy.

*Your new policy provides a time limit within which you may decide, without cost to you, whether you desire to keep the policy. The time limit is 10 days from the date of receipt of this policy.

*Health conditions which you presently may have might not be covered under the new policy. This change in coverage could result in a claim for benefits being denied under the new policy even though they are payable under your present policy.

*Questions in the application for the new policy must be answered truthfully and completely; if not, the validity of the policy and the payment of any benefits thereunder may be rescinded and voided.

 

By 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.

To the best of my knowledge and belief, I represent that all statements and answers I made in this application are complete and true.

9. Agent Statement


If yes, agent must complete the following:



I asked the applicant, spouse and all child(ren) over age 18 all questions contained in this application and recorded their answers exactly as given to me.

I also represent that no other person provided any of their answers, or influenced any of their answers; if any of their answers were influenced by another person, I have attached a written explanation thereof to this application.

10. Contact Information

Wisconsin Physicians Services Insurance Corporation
P.O. Box 8190
Madison, WI 53707

1-800-236-1448
www.wpsic.com

WPS Health Plan Inc. d/b/a Arise Health Plan
P.O. Box 11625
Green Bay, WI 54307

1-888-711-1444
www.WeCareForWisconsin.com