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: 25062-051-1607


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 enrolled in 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 Enrolled
in Medicare? *
 
Clear

Dependent Information

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

3. 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.

4. Information on Eligibility


If yes, please list which applicants:

5. Type of Coverage and Benefits Plan

A. Types of Coverage and Benefits Plan - Please refer to your policy for any non-participating provider benefits.
Arise & WPS Plans - Deductibles and out-of-pocket maximums listed below are for individuals. Family deductibles and out-of-pocket maximum are two times the individual. Please see summary of benefits and coverage for more detailed policy benefits.

Selection Metal Tiers Deductible Coinsurance
(amount you pay)
Out-of-
Pocket
Limit
Convenient
Care
Clinic Copay
PCP
Copay
Specialist
Copay
Preferred Generic/Non-Preferred
Generic/Preferred Brand/Non-
Preferred Brand/Specialty
Arise HMO
Arise POS
Bronze $7,150 0% $7,150 D/C D/C D/C D/C
Arise HMO HDHP
Arise POS HDHP
Bronze $5,500 20% $6,550 D/C D/C D/C D/C
Arise HMO
Catastrophic* $7,150 0% $7,150 D/C D/C D/C D/C
WPS PPO
Bronze $7,150 0% $7,150 D/C D/C D/C D/C
WPS PPO HDHP
Bronze $5,500 20% $6,550 D/C D/C D/C D/C
WPS PPO
Catastrophic* $7,150 0% $7,150 D/C D/C D/C D/C

D/C = Deductible and Coinsurance
PCP = Primary Care Practitioner
* 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. Primary Care Practitioner

If you are applying for coverage through Arise Health Plan, please select a Primary Care Practitioner (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 Practitioner *


D. 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.

6. 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
C. Medicare Eligible:
D. If you answered "Yes" to C. above, please indicate who:

*Please note, anyone named on this application who is enrolled for Medicare will not be covered by this policy.

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

Please check the method of payment you are requesting below: *





Account Holder Information:
Automatic Withdrawal
Payment Withdrawal Date:
Note:Recurring premium payments will be charged to your checking/savings account based on your selection above. We will continue to charge premiums until the policyholder notifies us to discontinue charging premiums in accordance with the Insurer's policy. If you do not choose a day, the payment pull will occur on the 20th of the month prior to the payment due date.
By my signature below, I authorize the Insurer to instruct my financial institution to deduct my premium payments from the account designated above. I authorize my financial institution to debit the amount of my premium from my designated account. This authorization will remain in effect until I notify the Insurer in writing of its termination. My notification must afford the Insurer and my financial institution reasonable opportunity to act on it.

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.

 

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. Terms and Conditions



I hereby enroll for coverage under the insurance coverage(s) for which I am presently eligible, or for which I may become eligible. I understand and agree that the information obtained by using this Application will be used by Insurer or Third Party Administrator (")TPA") to determine eligibility for benefits. I, on behalf of myself, my spouse and my dependent child(ren), if any, named herein, agree to cooperate in providing Insurer or TPA with information needed to process this Application.

I acknowledge that I have read and completed the entire Application. If I received assistance in reading or completing this Application, I have identified in the space provided below the person(s) who provided me with such assistance. I additionally agree that Insurer or TPA is not liable for any statement, representation, or other information provided to me, my spouse or my dependent child(ren) that is not expressly contained in a written document provided by Insurer or TPA and signed by an authorized officer of the insurer or TPA. I agree that no insurance will be effective until the date specified by the company on the policy after this application has been accepted. I also understand that if I decline any coverage, future changes in coverage are NOT automatic and may be subject to Insurer or TPA's approval.

11. Acknowledgements and Signatures

I acknowledge that:

  • This application becomes part of my Medical Coverage Agreement
  • The signatures shown below allow me, my spouse/domestic partner, or my agent (Section 9) to release to Insurer information about any person listed on my Individual and Family plan application documents.
  • Under the Health Insurance Portability and Accountability Act (HIPAA), Insurer, without my authorization, may only release limited information about my selection of a plan to my spouse/domestic partner, adult/minor children, producer, or anyone else.
  • Insurer may collect, use, or disclose the nonpublic personal information of persons listed on this application as required or permitted by law and to conduct routine business functions such as determining eligibility for enrollment, reviewing prior coverage for waiting periods, paying claims, and, if appropriate, coordinating benefits, and fulfilling other legal obligations specified in my Insurer Medical Coverage Agreement.
  • I have read and agree to the Terms and Conditions (Section 10) included with this application.
  • I authorize Insurer to disclose information about the selection of a plan to the Agent of Record (Section 9) for the duration of coverage and final reconciliation of the Insurer account. A signed Member Authorization to Disclose Health Plan Information form is required for all other disclosures to the Agent of Record.

I declare that, to the best of my knowledge, all information I have provided with this application is true and complete, and that all of the persons for whom I am requesting enrollment are eligible for coverage. I understand that if I have made intentionally false or misleading statements on behalf of myself or any family members, the Medical Coverage Agreement may be cancelled retroactively to its effective date. I further understand that it is a crime to knowingly provide false, incomplete, or misleading information for the purpose of fraudulently obtaining health coverage. Penalties may include imprisonment, fines, and denial of benefits.

Signature: This application has been signed by me and my spouse/domestic partner, if applicable.
If not the primary applicant, I am the:
     Parent
     Holder of Power of Attorney (attach legal documentation)
     Legal Guardian (attach legal documentation)

12. Contact Information

Arise Health Plan
P.O. Box 21341
Eagan, MN 55121

1-800-332-6249
www.arisehealthplan.com

WPS Health Insurance
P.O. Box 21341
Eagan, MN 55121

1-800-332-6421
www.wpsic.com