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EMPLOYMENT AND PERSONAL INFORMATION
Employer / Work Phone ( )
Name of Employee (last, first, mi) / Home Phone ( )
Address of Employee (street, city, state, zip) / q Single q Male
q Married q Female
Status: q Active q COBRA q MN Continuation q Other Leave / Employment Date: / Hours Worked/Week:
Job Title: / Duties:
Reason for COBRA, MN Continuation, or Other Leave:
/ Effective Date of COBRA, MN Continuation, or Other Leave:
PERSONS TO BE COVERED
Complete the following information for each person to be covered. Eligible dependents include your spouse and unmarried child(ren) under the age of 19 years. The dependent age limitation may be extended to age 25 for full-time students. Include the dependent(s) address if different from your address.
Name
(Include yourself and all family members to be covered.) /
Relationship /
Date of Birth (Mo/Day/Yr) / Social Security Number / Current Height (Ft/In) /
Current Weight / Has tobacco (in any form) been used in the past 12 months? /
Full-time Student?
Employee / q Yes q No
Spouse / q Yes q No
q Yes q No
q Yes q No
q Yes q No
q Yes q No
CURRENT COVERAGE INFORMATION
Are you or your dependents currently covered under another group health plan? q Yes q No
Are you satisfying a pre-existing condition limitation? q Yes q No
Name of current health plan ______Effective date of coverage with current health plan ______
Are you or your dependents covered under Medicare? q Yes q No If yes, name of person ______
HEALTH HISTORY
1. Are you or your dependents currently taking any medications or used any medications in the last 12 months? q Yes q No
If yes, complete the following:
Person / Medication / Condition / From: Dates To:
2. Are you, your spouse or dependents pregnant, exhibiting symptoms of pregnancy or anticipating adoption? q Yes q No
A. If yes, who? ______
B. When is birth or placement expected? ______
C. Have there been any complications, cesarean sections or multiple births in previous pregnancies? q Yes q No
D. Do you anticipate any complications, cesarean section, or multiple birth for this pregnancy? q Yes q No
3. Have you or your dependents: Yes No
A. had any signs or symptoms, including illnesses or injuries, for which a physician has not yet been consulted? q q
B. had any medical treatment, health impairment or congenital anomaly not already noted in this application? q q

- Continued on Reverse -

HEALTH HISTORY (continued)
4. Have you or your dependents ever had or been Yes No
treated for:
A. any disease or disorder of the eyes, ears, nose, q q
throat, tonsils or sinuses?
B. diabetes, or sugar, albumin or blood in the urine? q q
C. chest pain, shortness of breath, heart murmur, q q
angina, high blood pressure or any other heart or
circulatory disorder?
D. varicose veins, varicose ulcer, phlebitis, anemia q q
or any other vein or blood disorder?
E. arthritis, rheumatism, lupus, any disorder of the q q
joints, muscles or bones, any knee, back or spinal
disorder, TMJ, neuritis, sciatica or scoliosis?
F. eating disorders, unexplained weight loss, fatigue, q q q
fever, enlarged lymph, thyroid, adrenal,
pituitary or pancreas nodes/glands, skin lesions,
or any disorder of the immune system? / Yes No
G. stomach or duodenal ulcer, other ulcer, colitis, q q
diarrhea, hepatitis, or any disorder of the liver,
gall bladder, stomach, intestine or rectum?
H. kidney, bladder, prostate, or any other urinary q q
tract disorder, or any type of hernia?
I. any disease or disorder of the breast or q q
reproductive organs, infertility, abnormal
menstrual periods or any venereal disease?
J. stroke, epilepsy, fainting, dizziness, convulsions, q q
headaches or any disease or disorder of the brain
or nervous system?
K. tuberculosis, asthma, emphysema, bronchitis, q q
allergies, hay fever, lung or any other respiratory
disorder?
L. cancer or tumors, cysts or growths of any kind? q q
M. mental, emotional or personality disorders, q q
including counseling or hospitalization?
**disorder is a disease, illness, injury or condition differing in any way from the usual or normal state or structure.
5. Within the past 5 years have you or your dependents: Yes No
A. had a physical examination, electrocardiogram, laboratory or diagnostic test or x-ray (other than dental) or seen a q q
physician for any medical reason?
B. had surgery? q q
C. been advised to have surgery? q q
D. been evaluated for, treated for, or joined any organization for alcoholism/chemical dependency; been arrested for or q q
had a driver’s license suspended for driving while intoxicated; consumed alcohol to excess or used drugs improperly
or without physician approval?
E. been told to modify or restrict eating, drinking or living habits for health purposes? q q
F. had any blood test, including any screening for the presence of viral antibodies? q q
6. Have you or your dependents: Yes No
A. had any life or health insurance declined, postponed or modified, or had a waiver, rider or extra premium added? q q
B. received payment for disability, illness or injury? q q
C. been released from the military for medical reasons? q q
D. had a change in weight of more than 10 pounds in the last 12 months? q q
IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, DETAILS MUST BE PROVIDED. Use a separate sheet of paper if additional space is needed. Sign, date, and attach all extra pages.
Name of
Individual / Question
# &
Letter / Explanation of “YES” answers. Include condition, reason treated, or other details. / Date(s) of treatment
From: To: / Remaining
Effects / Name of Physician and/or Hospital where treated
IMPORTANT NOTICE - Please read carefully
I represent that all answers given are full, complete and true to the best of my knowledge, information and belief. I understand that: (1) the statements, answers and subsequent information I provide to the Program are the basis for coverage and are made part of the contract; (2) any material misstatements or failure to provide sought for information may be used as a basis of recision of my coverage; (3) coverage, if approved may be subject to a pre-existing condition limitation; (4) this form must be updated by me to include any condition or disease that may occur between the date of this form and the effective date of coverage; (5) if this form for new or additional coverage is accepted, coverage will not be effective until I am notified of the effective date.
AUTHORIZATION TO RELEASE INFORMATION
I am enrolling for coverage in the Minnesota Public Employees Insurance Program subject to approval of my eligibility. When applicable, I authorize my employer to deduct contributions from my earnings.
For underwriting and claims purposes, I give my permission to: any physician or other medical practitioner, hospital, clinic, pharmacy, health carrier, reinsurer, consumer reporting agency, or any other organization to give the health carriers and the employees of the Minnesota Public Employees Insurance Program’s administrative organization all information on my behalf as they apply to me or my dependents who are to be covered. I know that I have a right to a copy of this authorization. A photocopy of this authorization will be as valid as the original. This authorization will be valid for 26 months from the date shown below.
Employee’s Signature / Date / Spouse’s Signature / Date

Rev. 7/09 peip\forms\peiphh