APPLICATION FOR INSURANCE -- FIRST HEALTH LIFE & HEALTH INSURANCE COMPANY

UNIFORM QUESTIONNAIRE APPENDIX

PLEASE MAIL APPLICATION TO:

First Health Life & Health Insurance Company c/o Health Plan Services, Inc., P.O. Box 30466, Tampa, FL 33630-3466

I understand that any intent to defraud or knowingly facilitate a fraud against the First Health Life & Health Insurance Company by submitting an application or filinga claim containing a false or deceptive statement is insurance fraud.

This form, along with the Employee and Family Medical Questionnaire, are to be completed as evidence of an employee’s and his/her dependent’s health history when applying for group insurance. We cannot consider this request unless the form has been signed, dated, and all applicable questions have been completely answered in ink or typed. Modifications should be initialed by the applicant.

Employees applying for insurance coverage should complete the Application for Insurance section and sign the Certification and Authorization on the back.

Employees refusing insurance coverage should complete and sign the Waivers of Insurance Coverages section on the back of this form.

Case Number / Certificate Number
Employee Name / Employee Phone Number Fax Number
( ) ( )
Company Address
Home Address: Street City State Zip
Social Security #
______/______/______/ Marital Status
Married
Single
Date of Full-Time Employment
______/______/______
Month Day Year / Occupation / Annual Earnings
$
Are you now working for pay full-time at or from the above employer’s usual place of business? Yes  No
If yes, how many hours per week? ______hours/week
Do you presently have health insurance coverage with another carrier? Yes  No
If yes, is it group, individual or short-term coverage? ______
If yes, please provide name of insurance carrier. ______
Effective Date ______/______/______Expiration Date ______/______/______
Month Day Year Month Day Year
If no, what was the effective date and the expiration date of your most recent coverage?
Effective Date ______/______/______Expiration Date ______/______/______
Month Day Year Month Day Year
Beneficiary: Full Name Relationship Address
Who is to be insured:  Employee only Employee & Children  Life only
 Employee & Spouse Employee, Spouse & Children

THE FOLLOWING INFORMATION IS NEEDED TO PROPERLY UNDERWRITE OUR RISK. Any material omission or misrepresentation of medical information may result in retroactive termination of insurance coverage. (For group health insurance, this information will be used only to determine the initial premium rates for the entire group but only to the extent allowed by applicable state law. It will not be used to determine whether you or your dependents are eligible for group health insurance.)

Provide health information on all persons to be covered:

1.Have you or any of your dependents been treated for any medical condition during the last 12 months for which

medical expenses incurred exceeded $3,000?Yes No

2. Have you or any dependents ever been diagnosed as having, consulted a doctor or practitioner for, been

treated, tested or received therapy for Sexually Transmitted Disease?Yes No

If any of the previous questions were answered “yes”, please provide details below. If more room is needed to explain the medical condition, please use Medical Questionnaire:

Question # / Name of Person / Condition / Dates of Treatment / Treatment Given / Degree of Recovery

3. Have you ever been rated or declined for Life, Accident or Health Insurance or had such insurance postponed,

modified or renewal declined, or received disability payments for more than six (6) months?  Yes  No

If yes, please provide details:______

______

COMPLETE IF HIGH BLOOD PRESSURE IS REPORTED

Names of Persons Treated / List 3 Blood Pressure Readings
(2 within last year and 1 within last month)
Month _____ Year _____ Reading ______
Month _____ Year _____ Reading ______
Month _____ Year _____ Reading ______

With respect to all coverage except group health, I authorize any physician, medical practitioner, hospital, clinic or other medical or medically-related facility, insurance company, the MedicalInformation Bureau or other organization, institution or person having any information as to me or my health or that of my dependents, to give all such information to First Health Life & Health Insurance Company, its agents and its reinsurers. I certify that I have read the statements on this form or that they have been read to me, and that all the information was provided by me and is true and complete to the best of my knowledge. I understand that any material misrepresentation or omission contained herein and relied on by the Insurance Company may be used to rescind or void the contract within the contestable period. I further understand that no agent can modify this application, waive the answers to any questions, or suggest or complete the answers thereto.

Date ______Employee’s Signature______

Waiver information: I decline to enroll for the following coverage(s): Health Life Dental Disability

For: Myself My Spouse My Dependent Children. I decline to enroll for all coverages.

Reason for Declining: Covered by spouse’s coverage Other (explain) ______

If you are declining enrollment for yourself or for your eligible dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents for this group health insurance, provided you request enrollment within 31 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided you request enrollment within 31 days after the marriage, birth, adoption or placement for adoption.

I understand that should I request insurance at a later date, Late Entrant status may apply and I may be subject to a pre-existing condition exclusion.

Date ______Employee’s Signature for Waiver______

First Health Life & Health Insurance Company - 3200 Highland Avenue, Downers Grove, Illinois 60515

GC4000 EMP APP – AZ Uniform Questionnaire Appendix (05/2008)