United Healthcare Insured Employer Application

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Insured Employer Application UnitedHealthcaxe' Alkrtedlleaf~hGrauPCY To avoid processing delays, please make sure you: i. Answer all questions completely and accurately. 2. DO NOT CANCEL YOUR EXISTING COVERAGE UNTIL YOU RECEIVE WRITTEN NOTIFICATION OF APPROVAL 3. Include a deposit check in the amount of any required premiums; such amount will be returned in the event coverage does not become effective and will be applied against the first month's premium if coverage does become effective. Requested Effective Date 1 / 1 / 2 012 ~ ~ Group's/Company's Legal Name Orange County Street Address Tax ID . 200 S. Cameron Street St to Zip Code County Ctty Hillsborough Forth Carolina 27278 Orange Contact Person Telephone Fax Email Address Diane Shepherd (919) 245-2558 (919) 644-3009 dshepherd@co.orange.nc.us Billing Address (if different) ~ of Years in Business Post Office Box 8181, Hillsborough, North Carolina 27278 259 Mufti-location group/company? ~ of Locations Address {es) (or list on additional sheet of paper} I~Yes ONo Multiple All are located in Orange County Organization Type ^ Partnership D C-Corp ^ S-Corp O LLC/LLP Nature of Business Industry Code ^ Ind. Contractor D Sole Proprietor ~] OtherGovernment Local Government 9131 Waiting Period ~J 1st of Policy Month following Date of Hire Waiting Period waived Medical Benefit EBISA Plan? . for new hires D 1st of Policy Month #ollowing _ [months] [days) of employment Far initial enrollees Plan Option D Yes KJ No D Date of Hire (no waiting period} D Yes ®No f~l Calendar Year D ~ [months) [days} of employment following Date of Hire D Policy Year D Other Number of Persons currently on COBRAIContinua6on Number of Employees Termed Classes Excluded: ^ None O Union D Hourly and/or Short/Long Tarm Disability in last 12 Months DNon-Management DNon-Owners {employees/dependents) 9 O Temporary Namo of Workers' Compensation Carrier Names of Owners/Partners not covered by Workers' Compensation Sedgwick CMS N/A C7 By checking this box, I acknowledge that I do NOT want UnitedHealthcare to act as my COBRA or state continuation of coverage administrator. # Employees ~ Employees ~ Employer Employer ~ A in for. Waivin for: ~ °h % for De P Eligible Employees Medical Modica{ Medical 10 0 52 t Ineligible Employees Dental Dental. Dental Total i Employees Vision Vision Vision _. __ . ,; .^ : . • :"=->=s Basic EE life/AD&D Basic EE Life/AD&D Basic EE life/AO&D :=~r"w=~~i'- ~='` Basic De Life Basic Dep Life Basic De Life / Hours per week 2 0 Su EE Life/AD&D Supp EE Life/AD&D Su EE Life/AD&D to be eligible"" Su De lffe/AD&D Su De Life/AD&D Su De Life/AD&D STD STD STD ';~~~`Y> " "`~' For Disability products the STD Bu U STD Buy U STD Bu U '=-~ -~:.¢-~ minimum i of work hours per LTD LTD -~~- £ ~x~ -~:~t ~=:'~ ~~ =~ ".~: -~: week to be eligible is 30 hours. LTD ~ ` ~•"~''~J LTD Bu U Y P LTD Buy Up LTD Buy Up ~: s" ' Other Other Other Coverage provided by "UnitedHealthcare and Affiliates": Medical coverage provided by UnitedHealthcare Insurance Company [ar UnitedHealthcare of XXX} Dental coverage provided by UnitedHealthcare Insurance Company [or UnitedHeslthcare of XXX1 Life, Short-Term Disability [STD) and Long-Term Disability (LTD) Insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company Vision coverage provided by UnitedHealthcare Insurance Company page 1 of 4 Ixxx•xxxx alto] tG.ER.ta.XX 6/10