United Healthcare Insured Employer Application

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Does the group currently have any coverage with UnitedHealthcare orhas the group had any UnitedHealthcare coverage in the last 12 months? DYes K7 No If Yes, please provide policy number and Coverage Begin Date^.I._/ End Date_.J_/ _~ 1... ... . d,...ee1 c n,innc rnr thw oravimis t2 ronsecutive months? ]Yes ^ NO Name of C trier Coverage Begin Data Coverage End Daie CurrentMedicslCarriar ^Nona County Commissioners (NCACC) Pre-2005 12/31/2011 Current Dental Carrier ^ None n/ a Current Life Carrier ^ Nona n/a Current Short•Term Disability Carrier ^ None n/a Current Long-Term Disability Carrier ^ None n/ a 1 ~ It you are applying for medical coverage, please answer the following questions to the best of your knowledge by referencing available employee records and other personnel documents for all eligible employees and dependents (proprietors, partners, corporate officers, employees, spouses, and dependent children) to the extent permitted by applicable law. UnitedHealthcaro is antys~eking tocollect iniormationabout Ede current heath status of those employees and their dependentswho are applying for coverage. in answering these questions, do not include any genetic information about your employees or their dependents, including requests for genetic services, genetic diseases for which they may be at risk or family medical history information. Please provide details to "Yas" answers in the space provided. IMPDRTANT: Your answers to these questions must include all COBRA and State Continued individuals covered by your present plan. ^ Yes D No 1. Within the past 3 years, has any employee or dependent filed a claim for short-term disability, long term disability, social security disability income, workers' compensation, Medicare, or Medicaid benefits or any other type of disability benefits on any policy? DYes ^ No 2. During the past 3 years, has any employee or dependent had life, disability or health insurance declined, postponed, changed, cancelled or withdrawn? ^ Yes ^ No 3. Except far a maternity or paternity leave, within the past 3 years, has any employee applied for a family or medical leave of more than 2 weeks due to injury, disability or illness of the employee or dependent? O Yes ^ No 4. Within the past 3 years, has any employee been absent from work for more than 2 consecutive weeks due to injury, disability or illness? ~] Yes D No 5. Except for a mental health admission, during the past 3 years, has any employee or dependent had a hospital stay lasting more than 5 days or is any employee or dependent contemplating treatment that would require hospitalization for more than 5 days? DYes ^ No ti. Is any employee or dependent currently hoe 't~lized? ~ , '1, • DYes ^ No 7. Within the past 3 years has any emplo e a ~ endent beet~iagnosed, treated for, or cat ed, r_~@@scri lion medication for one of the following conditions? (refer C Rep s previo~us~Lw-~.~ett) p D Cancer (env type} ^ Hepatitis ~'"" ^ Lung disease or respiratory problem (any type) ^ Heart disease or disorder (any type) ^ Organ, tissue or cell transplant ^ Liver disease {any type) ^ Kidneydisease{anytype) ^ Pancreatic disorder {any type) ^ Diabetes ^ Morbid obesity ^ Congenital abnormality ^ Vascular disease (any type) ^ Neurological disorder (any type) O lmmunoiogical disorder (reportable types) ^ Alcohol or drug addiction or abuse . ...,._ .~___, ,e _______-..._.....rd:,:..ml eMeeee er nonor If you hav Question Number e answered Che Employee REFE "Yas" to a One De endent TO NC ny of t Age CC he question Date of fiecave REPOR s above, lease rovtua Date of Treatment/ Candhion S PREVIOUSLY the re uesteu rmormau Nature of Medication ROVIDED un rot ~~~~~ ~~~"~.~"~a, Name of Condition • ~~ ~~o~o~" $ Amount of Claims •,. ""- ---•••-••-• _..__._ _. _ _.. Current Treauent page 3 of 4