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) Health Savings Account for: m Myself I decline to apply for group coverage because of: m Spousal coverage Agreement True and complete acknowledgment I understand, agree, and represent: • I have read the Small Group Employee 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 Small Group Employee 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. • In the event that I should decide to apply for coverage hereafter, that subsequent Small Group Employee 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. m Medicare supplement m Individual coverage m Coverage under another carrier’s plan provided by my employer / group m Other:___________________________ • 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. • 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 Small Group Employee 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 Small Group Employee Enrollment Form. • An act of fraud or an intentional misrepresentation of a material fact may void or terminate an individual’s or group’s coverage as specified under the terms of the Policy or Certificate. Providing incomplete, inaccurate, or untimely information may reduce an individual’s or group’s coverage or may increase past premium. • Medical coverage will not be declined due to health status. • I have received a copy of the plan provider directory and disclosure that includes provider limitation rules, and any financial arrangements with providers. • 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 Small Group Employee Enrollment Form by Humana. • Any person who knowingly presents false information in an application for insurance or life settlement contract is guilty of a crime and, upon conviction, may be subject to fines or confinement in prison, or both. • For applicable Workplace Voluntary Benefits, you acknowledge and attest to the following: THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. If you decide not to sign this agreement, we will decline to enroll you in an insurance product or to give you insurance benefits.
20 | Slappey & Sadd, LLC 2025 Benefits Guide GA-72000 10/2015
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Reorder# GA-52000-SB 1/2018
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