Fillable Printable Humana Application Form
Fillable Printable Humana Application Form
Humana Application Form
TN-72000 5/2013 1 Reorder# TN-52000-SB 1/2014
Proposed effective date: _ _ / _ _ / _ _ _ _
Employer / Group name Employer / Group city State
Please print clearly and fill in each applicable circle.
The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in the Small Group
Employee and Individual Application and Enrollment Form as “Humana”. To elect primary care physician or dentist, please
complete reorder TN-51340-PP.
PPO and Classic plans insured or administered by Humana Insurance Company. HMO plans offered by Humana Health Plan, Inc. Humana National POS plans
offered by Humana Health Plan, Inc. and insured or administered by Humana Insurance Company. Dental plans insured or administered by HumanaDental
Insurance Company or Humana Insurance Company. Vision plans insured or administered by Humana Insurance Company. Short Term Disability,and Long Term
Disability,and Life,and Workplace Voluntary Benefits plans insured or administered by Kanawha Insurance Company.
Qualifying Event Instructions Date of Qualifying Event: _ _ / _ _ / _ _ _ _
m New business enrollment m Open Enrollment event m Dependent birth or adoption m Loss of coverage
m New hire / Newly eligible m Rehire / Reinstatement m Marital status change m Other___________________
Visit us at Humana.com
Prior / Existing Coverage: IMPORTANT - DO NOT cancel any existing coverage until you receive written notification
from Humana of your acceptance for coverage.
1. Prior medical coverage during the past 18 months (individual or other group coverage)? m N m Y
Prior medical insurance carrier name Policy #
Prior coverage type:
m Employee / Individual only m Employee / Individual and spouse
m Employee / Individual and child(ren) m Family
Effective date _ _ / _ _ / _ _ _ _
Term date _ _ / _ _ / _ _ _ _
2. Other medical coverage in effect at the same time as this Humana coverage (individual or other group coverage)? m N m Y
Other medical insurance carrier name Policy #
Other coverage type:
m Employee / Individual only m Employee / Individual and spouse
m Employee / Individual and child(ren) m Family
Effective date _ _ / _ _ / _ _ _ _
Term date _ _ / _ _ / _ _ _ _
Medical
Social Security Number Street address APT / Suite / Box
City State ZIP code Phone # ( )
Language: m English m Spanish m Other
E-mail address Occupation
Employment status (check one) m Active m Retiree m COBRA
Annual salary $
Enrollment Information
Group Employee and Individual Application and Enrollment Form - 1-100 Employees Tennessee
Employee / Individual Information
Hours worked per week: Date of full time hire: _ _ / _ _ / _ _ _ _
3. Medicare
Employee / Individual coverage: m N m Y
Medicare ID Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _
Spouse coverage: m N m Y
Medicare ID Effective date _ _ / _ _ / _ _ _ _ Term date _ _ / _ _ / _ _ _ _
Relationship Last name, First name MI Gender Date of birth
Disabled?
If yes, indicate reason below.
Social
Security Number
Employee /
Individual
m F
m M
_ _ / _ _ / _ _ _ _
m Y
m N
N/A (complete in
Employee/ Individual
Information section.)
Spouse /
Domestic Partner
m F
m M
_ _ / _ _ / _ _ _ _
m Y
m N
Child /
Dependent
m F
m M
_ _ / _ _ / _ _ _ _
m Y
m N
Child /
Dependent
m F
m M
_ _ / _ _ / _ _ _ _
m Y
m N
Child /
Dependent
m F
m M
_ _ / _ _ / _ _ _ _
m Y
m N
Other (specify):
m F
m M
_ _ / _ _ / _ _ _ _
m Y
m N
Rate Amount $_______ Rate Frequency (Monthly)
Rate Amount $_______ Rate Frequency (Monthly)
Rate Amount $_______ Rate Frequency (Monthly)
Rate Amount $_______ Rate Frequency (Monthly)
Rate Amount $_______ Rate Frequency (Monthly)
Rate Amount $_______ Rate Frequency (Monthly)
Rate Amount $_______ Rate Frequency (Monthly)
Rate Amount $_______ Rate Frequency (Monthly)
TN-72000 5/2013 2 Reorder# TN-52000-SB 1/2014
First name:Last name:
Vision
Group #:
Benefit #: Class/Div:
Coverage type:m Employee / Individual only
m Employee / Individual and spouse
m Employee / Individual and child(ren)
m Family
m No Coverage (complete waiver)
Dental
1. Prior dental coverage during the past 12 months (individual or other group coverage)? m N m Y
2. Prior orthodontia coverage in the past 12 months? m N m Y
Prior dental insurance carrier name Policy # Prior coverage type:
m Employee / Individual only
m Employee / Individual and spouse
m Employee / Individual and child(ren)
m Family
Effective date _ _ / _ _ / _ _ _ _
Prior carrier phone # ( ) Term date _ _ / _ _ / _ _ _ _
Medical Group #:
Benefit #: Class/Div:
Coverage type: m Employee / Individual only m Employee / Individual and spouse
m Employee / Individual and child(ren) m Family m No Coverage (complete waiver)
Plan name:
Coverage Options
Health Savings Account Group #:
Benefit #: Class/Div:
If you have medical coverage under another plan, you may not be eligible for an HSA. Please check with your tax advisor for details.
Please refer to Humana’s HSA contribution worksheet to calculate your maximum allowed contribution. You can nd additional information on
HSAs on Humana.com. Select the Quick Link for Spending Account information on the Member page.
Do you elect the Health Savings Account?
m N m Y (If no, complete waiver.)
Beneciary for this account will be the employee / individual’s estate. You may change beneciary
information on le with the bank that administers the HSA once the account is established.
Basic Life / AD&D Group #:
Benefit #: Class/Div:
Basic dependent life
m N m Y (If no, complete waiver.)
Class (employer will provide you with this information, if needed)
Voluntary Life / AD&D
Group #:
Benefit #: Class/Div:
Voluntary employee / individual life
coverage m N m Y
Amount (min $15,000)
$
Voluntary spouse life
coverage? m N m Y
Amount (min $5,000)
$
Voluntary child(ren) life coverage?
m N m Y
Short Term Disability
Group #: Benet #: Class: Div:
Short Term Disability m N m Y (If no, complete waiver.) Buy-up percent/amount _______
Long Term Disability
Group #: Benet #: Class: Div:
Long Term Disability m N m Y (If no, complete waiver.) Buy-up percent/amount _______
Plan name:
Dental Group #:
Benefit #: Class/Div:
Coverage type:m Employee / Individual only
m Employee / Individual and spouse
m Employee / Individual and child(ren)
m Family
m No Coverage (complete waiver)
Plan name:
TN-72000 5/2013 3 Reorder# TN-52000-SB 1/2014
First name:Last name:
Workplace Voluntary Benefits: Optional riders availability based on employer / group election.
Accident Group #:
Benefit #: Class: Div:
m Accident m N m Y Benet Level: m1 m2 m3 m4
Coverage type: m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family
mOptional Hospital Intensive Care Unit Benets Rider
m$150 m$300 m $450 m$600
mOptional Fracture and Dislocation Benets Rider
m$750 m$1,500
mOptional Accident Total Disability Benets Rider: Elimination Period:m1 Daym7 Daysm14 Daysm30 Days
Elimination Benet:m$400m$500 m$600 m$700 m$800m$900m$1000
Disability Income Plus Group #: Benefit #: Class:
Div:
m Disability Income Covering Accident and Sickness m N m Y
Base Benet Period: m3 Month m6 Month m1 Year m2 Year m3 Year
Base Elimination Period: m 0/7 m7/7 m0/14 m14/14 m30/30 m60/60
m90/90 m180/180 m365/365
Monthly
Benet
$
m Disability Income Covering Accident and Sickness with Waiver of Elimination Period m N m Y
Base Benet Period: m3 Month m6 Month m1 Year m2 Year m3 Year
Base Elimination Period: m 0/7 m7/7 m0/14 m14/14
Optional Disability Income Benets: m ICU / CCU Benet m $200 m $400 m $600 m $800
m Physical Therapy Benet m COBRA Rider
Whole Life / AD&D Group #: Benefit #: Class: Div:
m Whole Life / AD&D m N m Y m Whole Life 99 m Whole Life 65
Employee / Individual Benet $
mAD&D Rider mAutomatic Premium Loan Option
mAutomatic Benet Increase Rider
m$1 / Week
m$2 / Week
mEmployee / Individual Term Rider to 65
Employee / Individual Benet
$
mFamily Term Rider
Spouse Benet Child(ren) Benet
$ $
Disability Income Advantage Group #: Benefit #: Class: Div:
m Disability Income Advantage m N m Y
Base Benet Period: m3 Month m6 Month m1 Year m2 Year m3 Year
Base Elimination Period: m 0/7 m7/7 m0/14 m14/14 m30/30 m60/60
m90/90 m180/180 m365/365
Monthly
Benet
$
Optional Riders: mHospital Confinement mCOBRA Rider
COBRA Monthly Benet $
Whole Life Spouse / AD&D Group #: Benefit #: Class: Div:
m Stand Alone Spouse / AD&D m N m Y
m Whole Life 99 m Whole Life 65
Spouse Benet $
mAD&D Rider mFamily Term Rider (Child Coverage Only)
Child(ren) Benet Amount $
mAutomatic Premium Loan Option
COBRA Monthly Benet $
Accident - 2012 Group #: Benefit #: Class: Div:
m Accident m N m Y Benet Level: m1 m2 m3 m4
Coverage type: m Employee / Individual only m Employee / Individual and spouse m Employee / Individual and child(ren) m Family
TN-72000 5/2013 4 Reorder# TN-52000-SB 1/2014
First name:Last name:
Critical Illness Group #: Benefit #: Class: Div:
m Critical Illness m N m Y
m Critical Illness and Cancer m N m Y
Coverage type: m Employee / Individual only m Employee / Individual and spouse
m Employee / Individual and child(ren) m Family
Optional Benets: mAutomatic Benet Increase mHealth Screening m Return on Premium
Employee / Individual Benet $
Does anyone on this application have a parent, brother, or sister with a history of heart attack, heart disease, stroke, or cancer
diagnosis prior to age 60? m N m Y If yes, please indicate whether this applies to you (Employee / Individual), your spouse or a dependent.
m You (Employee / Individual) m Spouse m Dependent Name_____________________________________________
Supplemental Health Group #: Benefit #: Class: Div:
mSupplemental Health m N m Y Coverage type: m Employee / Individual only m Employee / Individual and spouse
m Employee / Individual and child(ren) m Family
Plan type: m1 m2 m3 m4
Cancer Expense Group #: Benefit #: Class: Div:
m Cancer Expense m N m Y Coverage type: m Employee / Individual only m Employee / Individual and spouse
m Employee / Individual and child(ren) m Family
mLump Sum Benet (Equal to 50% of Base Benet Amount) Rider: mHospital Indemnity Rider
Base Benet $
Beneficiary Information for Life, Disability and Workplace Voluntary Benefits
Primary beneciary name (Last, First MI) Relationship to Employee / Individual
Secondary beneciary name (Last, First MI) Relationship to Employee / Individual
Group Lump Sum Cancer Group #: Benefit #: Class: Div:
mGroup Lump Sum Cancer m N m Y
Coverage type: m Employee / Individual only m Employee / Individual and spouse
m Employee / Individual and child(ren) m Family
Does anyone on this application have a parent, brother, or sister with a history of cancer diagnosis prior to age 60 ? m N m Y
If yes, please indicate whether this applies to you (Employee / Individual), your spouse or a dependent.
m You (Employee / Individual) m Spouse m Dependent Name________________________________________________________
Rider: m Automatic Benefit Increase m Health Screenings
Base Benet $
Level Term Life Group #: Benefit #: Class:
Div:
m Level Term Life / AD&D m N m Y Coverage type: mEmployee / Individual only
mSpouse mChild(ren)
Base Plan: m10-Year Term m20-Year Term
Optional Benet: m Automatic Benet Increase
Employee / Individual Benet
$
Spouse Benet
$
Child(ren) Benet
$
If your employer or group has elected the critical illness rider, have you or any dependent had a parent, brother, or sister with
a history of heart attack, heart disease, stroke, or cancer diagnosis prior to age 60 ? m N m Y
If yes, please indicate whether this applies to you (Employee / Individual), your spouse or a dependent.
m You (Employee / Individual) m Spouse m Dependent Name________________________________________________________
Whole Life Child(ren) / AD&D Group #:
Benefit #: Class: Div:
m Whole Life Child(ren) / AD&D m N m Y
Child(ren) listed here must also be included as dependents under the Enrollment Information section of this application.
m N m Y Coverage on Child 1
Child 1 Name Child 1 Benet $
m N m Y Coverage on Child 2
Child 2 Name Child 2 Benet $
m N m Y Coverage on Child 3
Child 3 Name Child 3 Benet $
TN-72000 5/2013 5 Reorder# TN-52000-SB 1/2014
First name:Last name:
a.
Coronary artery disease, chest pain, heart surgery, or
any disease of the arteries, or blood disorders; anemia;
hemophilia; phlebitis; high blood pressure (reading higher
than 140/90)?
m N
m Y
g.
Diabetes; liver or thyroid disease; hepatitis; cirrhosis; or
enlargement of the lymph nodes?
m N
m Y
b.
Nervous, mental or emotional disorder; convulsions;
epilepsy; unconsciousness; Multiple Sclerosis; Parkinson’s
Disease; Cerebral Palsy?
m N
m Y
h.
Rheumatoid arthritis; or back disorders; or joint disorders?
m N
m Y
c.
Stroke; Transient Ischemic Attack (TIA)?
m N
m Y
i.
Paralysis, or any other physical impairment or deformity?
m N
m Y
d.
Emphysema; asthma, or other disease of lungs, or
respiratory organs?
m N
m Y
j.
Chronic Fatigue Syndrome/Fibromyalgia?
m N
m Y
e.
End stage renal disease; disease of kidney?
m N
m Y
k.
Diseases of the eye, ear, nose, or throat? Disease or
disorder which has led or may lead to a permanent or
progressive loss of vision, hearing or speech?
m N
m Y
f.
Cancer, and/or cancerous tumor; including skin cancer?
m N
m Y
l.
Alcoholism or drug habit?
m N
m Y
5. Has anyone on this application been advised by a member of the medical profession to have any diagnostic test,
hospitalization, or surgery that has not been completed within the past 5 years?
mN m Y
Evidence of Health Status
Complete this section if you are selecting workplace voluntary (excludes Accident), disability, and/or life, benefits.
1a. In the past 12 months has any applicant used any tobacco product? If yes, applies to:
m Employee m Spouse/Domestic Partner m Otherm Child/Dependent names__________________________
mN m Y
1b. Is any applicant currently a smoker? If yes, applies to:
m Employee m Spouse/Domestic Partner m Otherm Child/Dependent names__________________________
mN m Y
2. In the past 12 months, have you missed 5 or more consecutive days of work due to an injury or illness other than as a result
of a cold, the flu, back problems, strained/sprained/fractured/broken limb or as a result of pregnancy?
mN m Y
3. Has anyone on this application been diagnosed or received treatment for an immune system disorder (i.e. Lupus, ITP), AIDS
or an AIDS-related complex?
mN m Y
4. Within the past 5 years, has anyone on this application been diagnosed with diseases or disorders related to, counseled, consulted, or
treated by a doctor, including surgery, for any of the following:
Complete this section for 2-50 groups selecting medical benefits only
1a. In the past 12 months has any applicant used any tobacco product? If yes, applies to:
m Employee m Spouse/Domestic Partner m Otherm Child/Dependent names__________________________
mN m Y
1b. Is any applicant currently a smoker? If yes, applies to:
m Employee m Spouse/Domestic Partner m Otherm Child/Dependent names__________________________
mN m Y
TN-72000 5/2013 6 Reorder# TN-52000-SB 1/2014
First name:Last name:
For groups 51-100, complete this section if you are selecting medical benefits only. For groups 2-50 selecting
medical benefits only, do not complete this section.
1. Is anyone on this application covered currently pregnant? If yes, please indicate anticipated delivery date below.
Anticipated delivery date:
mN m Y
2. In the past 12 months, have you missed 5 or more consecutive days of work due to an injury or illness other than as a result
of a cold, the flu, back problems, strained/sprained/fractured/broken limb or as a result of pregnancy?
mN m Y
3. Has anyone on this application been diagnosed or received treatment for an immune system disorder (i.e. Lupus, ITP),
AIDSor an AIDS-related complex?
mN m Y
4. Is anyone on this application currently taking any prescribed medication, or do you periodically take medication for a
recurrent condition?
mN m Y
5. During the last 24 months, has anyone on this application been diagnosed with, or treated for, any illness or injury or had
surgery or hospitalization recommended?
mN m Y
6. Within the past 12 months, has anyone on this application incurred covered medical expenses in excess of
$10,000?
mN m Y
Medical Health History - Do not submit more than 90 days prior to the effective date.
If you answered “yes” to any of the questions above, please provide details below and specify the question number. Attach
additional signed and dated sheets (reorder TN-51340-MH), if necessary.
Question # Person treated (Last name, First name)
Condition Treatments received
Medications prescribed Current or future treatments or medications
Date diagnosed _ _ / _ _ / _ _ _ _ Date last seen by a doctor _ _ / _ _ / _ _ _ _
Relationship
Last name, First name MI
Height
(ft / in)
Weight
(lbs)
Employee
/
Spouse / Domestic Partner
/
Child / Dependent
/
Child /Dependent
/
Child /Dependent
/
Other (specify):
/
TN-72000 5/2013 7 Reorder# TN-52000-SB 1/2014
First name:Last name:
Waiver (refusal of coverage)
I acknowledge that I have been given the opportunity to apply for group coverage available to me and my dependents through my employer / group.
I proclaim that I was not pressured or forced by my employer / group, the writing agent, or Humana into waiving (declining) coverage. If I have
waived any coverage offered to me or my dependents, my signature is evidence of this action.
I hereby waive coverage for (check all that apply):
Medical for: m Myself m My spouse m My dependent child(ren)
Dental for: m Myself m My spouse m My dependent child(ren)
Basic Life for: m Myself m My spouse m My dependent child(ren)
Vision for: m Myself m My spouse m My dependent child(ren)
Short Term Disability for: m Myself
Long Term Disability for: m Myself
Health Savings Account for: m Myself
Waive Coverage for Workplace Voluntary Benefits:
Whole Life for: m Myself m My spouse m My dependent child(ren)
Level Term Life for: m Myself m My spouse m My dependent child(ren)
Critical Illness for: m Myself m My spouse m My dependent child(ren)
Group Lump Sum Cancer for: m Myself m My spouse m My dependent child(ren)
Cancer Expense for: m Myself m My spouse m My dependent child(ren)
Supplemental Health for: m Myself m My spouse m My dependent child(ren)
Accident for: m Myself m My spouse m My dependent child(ren)
Disability Income Plus for: m Myself
Disability Income Advantage for: m Myself
I decline to apply for group coverage because of:
m Spousal coverage
m Medicare supplement
m Individual coverage
m Coverage under another carrier’s plan
provided by my employer / group
m Other:
_______________________________
Agreement
True and complete acknowledgement
I understand, agree, and represent:
• I have read the Group Employee and Individual Application and Enrollment Form or it has been read to me and answers provided are true and complete
to the best of my knowledge and belief.
• Neither my employer / group nor the agent can waive any question, determine coverage or insurability, alter any contract or waive any of Humana’s other
rights and requirements.
• If the Group Employee and Individual Application and Enrollment Form for coverage is accepted, coverage will be effective on the date specified by
Humana on the policy or certificate.
• If I have a new dependent as a result of a qualifying event, I may in the future be able to enroll myself or my dependents provided I request enrollment
within 31 days after the qualifying event.
• If I or my dependents become eligible for premium or rate subsidies under Medicaid or the Children’s Health Insurance Program (CHIP), I may in the
future be able to enroll myself or my dependents provided I request enrollment within 60 days after the qualifying event. I understand eligibility for
enrollment does not apply to a High Deductible Health Plan (HDHP).
• In the event that I should decide to apply for coverage hereafter, that subsequent Group Employee and Individual Application and Enrollment Form shall
be subject to the applicable terms and conditions of the master group contract(s), policy provisions or certificate provisions which may require additional
limitations and waiting periods.
• Based on the coverage I have elected, I may be required to furnish evidence of health status satisfactory to Humana.
• If I am declining coverage for myself or my dependents (including my spouse) because of coverage under Medicaid or CHIP, I may in the future be able to
enroll myself or my dependents provided that I request enrollment within 60 days after my coverage under these programs ends. I understand eligibility
for enrollment does not apply to an HDHP.
• If I am declining coverage for myself or my dependents (including my spouse) because of other coverage, I may in the future be able to enroll myself or
my dependents provided that I request enrollment within 31 days after my other coverage ends.
• Humana reserves the right to delay medical coverage and/or deny life or dental coverage with any future submissions of the Group Employee and
Individual Application and Enrollment Form for coverage.
• If any deductions are required for this coverage, I authorize those deductions from my earnings. If selecting the Health Savings Account (HSA), I authorize
Humana or its banking partners to provide my account number to my employer / group for the purposes of depositing any contributions.
• If I am applying for coverage for my dependents (including my spouse) I attest by my signature below, I have gathered the necessary health information
from my dependents in order to fully and truthfully complete the Group Employee and Individual Application and Enrollment Form.
• If I have selected workplace voluntary benefits, and if coverage is not issued as initially applied for, I hereby authorize Humana to decrease or increase the
premium or rate amount stated on the Group Employee and Individual Application and Enrollment Form to cover the benefit actually issued.
• An act of fraud or an intentional misrepresentation of a material fact may void or terminate an individual’s or group’s coverage as specied under the
terms of the Policy or Certicate. Providing incomplete, inaccurate, or untimely information may void, reduce, or increase past premium, or terminate an
individual’s coverage or the group’s coverage.
• Rates or premium quoted and the effective date requested are not guaranteed. The final rate or premium and effective date will be determined upon
underwriting review and approval of the Group Employee and Individual Application and Enrollment Form by Humana.
• It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.
Penalties include imprisonment, fines and denial of insurance benefits.
If you decide not to sign this agreement, we will decline to enroll you in an insurance product or to give you insurance benefits.
TN-72000 5/2013 8 Reorder# TN-52000-SB 1/2014
First name:Last name:
Authorization
My dependents and I understand and agree:
• The information obtained by use of this authorization may be used by Humana to make claims determinations, determine eligibility for coverage,
eligibility for benefits under an existing policy and plan administration.
• Any information obtained will not be released by Humana to any person or organization except to reinsuring companies, the Medical Information
Bureau, Inc. or other persons or organizations performing health care operations or business or legal services in connection with the Group
Employee and Individual Application and Enrollment Form, claim or as may be otherwise lawfully required, or as I (we) may further authorize.
Authorization for Release of Medical Records for Life or Disability
If my dependents or I have selected life or disability, I authorize any third party to have information regarding myself. This includes any medical or
non-medical information and to share any and all such information with Humana, its reinsurer or its legal representatives, and its affiliates. Once
personal and health (including medical, dental, and pharmacy) information is disclosed pursuant to this authorization, the recipient may redisclose it
and the information may not be protected by federal and state privacy requirements.
The Group Employee and Individual Application and Enrollment Form, together with any supplemental forms, will make up part
of any contract and be the basis for any policy or certificate.
Signature - please sign below if enrolling or waiving group coverage.
If you decide not to sign this authorization, Humana cannot complete your plan enrollment or determine your premium rate due
to the inability to obtain the necessary information.
Employee / Individual or legal representative signature: ____________________________________ Date: _____________________
Name and relationship of legal representative: ________________________________________________________________________
Spouse signature: _______________________________________________________________ Date: _________________________
(Only if selecting Life coverage over the guarantee issue amount.)
Agent / Producer Information
If applying for workplace voluntary benefits, this section to be completed by Agent or Producer.
1. Agent / Agency of Record: 2. Agent / Agency of Record:
Name (print) Name (print)
Humana Agent # Humana Agent #
Commission split: Commission split:
1. Writing Agent / Producer: 2. Writing Agent / Producer:
Name (print) Name (print)
Humana Agent # Humana Agent #
Commission split: Commission split:
Will the coverage selected replace or change any existing life or disability insurance policy(s) and/or annuity(s)? m N m Y
As the Writing Agent / Producer, I acknowledge that I am responsible to meet with the primary applicant submitting the Group Employee and
Individual Application and Enrollment Form in order to fully and accurately represent the terms and conditions of the plans and services of the
offering or insuring entity, or one of its subsidiaries. These provisions are available to me and the primary applicant in the benefit summary document
or other plan literature.
Signed at _________________________________________________________________________ _______________________
County State
Writing Agent’s Signature _______________________________________________________________ Date __ __/__ __/__ __ __ __
The original version of this Agreement is in the English language. If there are any discrepancies or conicts between the English and any other version that has been translated into
another language, the English version will control.
