Individual Policy Application

If you are enrolled in Medicare, you cannot be covered by this policy. Please click here to see information on our Medicare Supplement plans. Are you (primary applicant) currently enrolled in Medicare?*

Yes No

Marital Status: *
Single Married Divorced Widowed Do you authorize us to disclose protected health info via electronic means?
Yes No Race or ethnicity:
Please select an ethnicity... Caucasian/White African American/Black Alaskan American Indian or Native Asian Hispanic or Latino Native Hawaiian or Pacific Islander Southeast Asian Two or more races Other Please enter other race/ethnicity: What primary language is spoken in your home?
Please select a language... English Albanian Arabic Chinese French German Hmong Korean Laotian Pennsylvania Dutch Polish Russian Spanish Tagalog Vietnamese Other Please enter other language:

 

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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? *
				M F		Yes No	Clear

Dependent Information

	Last Name *	First Name *	Middle Initial	Birth Date *	Gender *	Social Security # *	Relationship to Applicant *	Currently Enrolled in Medicare? *
1.					M F		Please choose... Daughter Grandchild Son	Yes No	Clear
2.					M F		Please choose... Daughter Grandchild Son	Yes No	Clear
3.					M F		Please choose... Daughter Grandchild Son	Yes No	Clear
4.					M F		Please choose... Daughter Grandchild Son	Yes No	Clear
5.					M F		Please choose... Daughter Grandchild Son	Yes No	Clear
6.					M F		Please choose... Daughter Grandchild Son	Yes No	Clear
7.					M F		Please choose... Daughter Grandchild Son	Yes No	Clear

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

 

Policy Effective Date: *

 

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

A. Within the past six months, has anyone named in this application who is age 18 or over used a tobacco product regularly, including chewing tobacco, (four or more times per week on average)? *
Yes No
If yes, please list which applicants:

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B. Are you applying due to a qualifying event (special enrollment)? *
Open enrollment is now closed. To enroll for coverage, you must have a qualifying special enrollment event.
Yes No If yes, choose:
Please select a value... Involuntary loss of Minimum Essential Coverage for any reason other than fraud, intentional misrepresentation of a material fact or failure to pay premium Previous coverage under COBRA Marriage (At least 1 spouse has to demonstrate they had minimum essential coverage within the 60 days preceding) (At least 1 spouse has to demonstrate they had minimum essential coverage within the 60 days preceding) Birth Adoption or placement for adoption or appointment of guardianship Renewal of Non-calendar year policy Placement in foster care Permanent move and had minimum essential coverage within 60 days Other COBRA start date: *
Please enter other information: Please provide the date of the qualifying event:

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	Preventive/Preferred Generic/Non- Preferred Generic/Preferred Brand/Non- Preferred Brand/Specialty
Arise HMO	Bronze	$4,500	20%	$7,350	D/C	D/C	D/C	$0 preventive, D/C all others
Arise HMO Arise POS	Bronze	$7,350	0%	$7,350	D/C	D/C	D/C	$0 preventive, D/C all others
Arise HMO HDHP Arise POS HDHP	Bronze	$5,500	20%	$6,650	D/C	D/C	D/C	$0 preventive, D/C all others
Arise HMO HDHP	Bronze	$6,650	0%	$6,650	D/C	D/C	D/C	$0 preventive, D/C all others
Arise HMO	Catastrophic*	$7,350	0%	$7,350	D/C	D/C	D/C	$0 preventive, D/C all others
WPS PPO	Bronze	$4,500	20%	$7,350	D/C	D/C	D/C	$0 preventive, D/C all others
WPS PPO	Bronze	$7,350	0%	$7,350	D/C	D/C	D/C	$0 preventive, D/C all others
WPS PPO HDHP	Bronze	$5,500	20%	$6,650	D/C	D/C	D/C	$0 preventive, D/C all others
WPS PPO HDHP	Bronze	$6,650	0%	$6,650	D/C	D/C	D/C	$0 preventive, D/C all others
WPS PPO	Catastrophic*	$7,350	0%	$7,350	D/C	D/C	D/C	$0 preventive, D/C all others

D/C = Deductible and Coinsurance
PCP = Primary Care Practitioner
* Eligibility limited to persons under age 30 or those with a hardship exemption from the Federally Facilitated Marketplace.

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B. Coverage Selection

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

Please select a coverage... Applicant Applicant & Spouse Applicant & Child(ren) Applicant, Spouse & Child(ren)

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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 *
Primary Applicant:
Spouse:
Dependent 1:
Dependent 2:
Dependent 3:
Dependent 4:
Dependent 5:
Dependent 6:
Dependent 7:

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D. Dental Benefit Plan (administered through Delta Dental of Wisconsin)

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

Are you applying for dental coverage? *
Yes No

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.

A. Other Coverage Does any person applying for coverage currently have other individual or group health coverage? *
Yes No

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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?
					Yes No	Clear
					Yes No	Clear
					Yes No	Clear
					Yes No	Clear
					Yes No	Clear
					Yes No	Clear
					Yes No	Clear
					Yes No	Clear
					Yes No	Clear

C. Medicare Eligible: Is any person named on this application currently eligible for Medicare? *
Yes No
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.

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.

 

Did an agent or sales representative assist you in the completion of this application?
Yes No

If yes, agent must complete the following:

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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.

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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.