2014 Application Checklist for Producers – Utah
Please read carefully and make sure all sections of the application are answered completely.
Use ink to complete, sign and date the application to avoid having it returned to the applicant.
Utah Individual Application Cover Sheet
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Section 1 – General information – Required – Complete legibly
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Section 2 – Eligible to Apply for Coverage – Informational only, dates subject to change
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Section 3 – Plan Selection- Medical Plans & Provider Networks – Required: Select a plan and a
network. A letter will be sent requesting the Plan selection or Provider Network if not provided.
Application cannot be processed until they are both selected.
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Section 4 – Tobacco Abstinence Certification Statement – The applicant’s signature and date
are required unless, e-signed. If not signed/dated by everyone over 18 on the application, they
will be given Tobacco user rates.
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Section 5 – Effective Date - Changes made will allow applications to be submitted until midnight
the last day of the month for 1st of the following month effective date.
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Section 6 - Member Card – Will default to Family Level Card if not selected.
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Section 7 – Child Custody Information - Required: In family situations involving divorce or
separations, this section needs to be completed & court documentation will be requested if not
provided with application.
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Section 8 – Continuing Coverage – Required: Check the appropriate box. If marked yes, legibly
provide the information requested.
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Section 9 – Acknowledgement – Informational only
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Section 10 – Your Privacy – Informational only
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Section 11 – Producer Information - Required: No agent will be entered into system until
valdidated. Missing information could delay commissions or interfere with producer inquiries on
client’s behalf.
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Section 12 – Premium Billing Options: To be completed ONLY if different than mailing address.
Ensure that complete billing address is provided. Payment options: Will default to “Monthly” if not
selected or EFT information is not provided.
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Section 13 – Consent to Electronic Distribution: Will default to No if not completed.
Additional Notes: As the completed application is a required part of the member’s contract, we can’t accept
re-dated, post-dated, re-submitted applications, or inserted pages of a previously submitted application. All
applications submitted must be reviewed by ALL applicants 18 and older prior to signing. If faxing applications
to your client, make sure all pages are faxed and received. Faxing signature pages only is unacceptable and
applications will be considered invalid and a new one will be requested.
Utah Individual Health Insurance Application
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Section A – Applicant Information – Required: Legibly complete each field in the section. If a portion
of this section is not completed, the application may be returned. Note: if applicant marks “Yes” to
having eligible immigration status, please include a copy of documentation to speed review process.
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Section B – Applicant and Dependent Information – Required: Legibly complete each field in the
section and the residency question, if applicable.
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Section C – Current Coverage Information – Required: If any applicant has current coverage, provide
all requested information. Leave “End Date” field blank if current coverage will continue.
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Section D – Employment Information – Complete all fields as applicable.
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Section E – Acknowledgment and Signature – Required: Applicant and spouse (if applying for
coverage) must review, sign and date. Requested Effective date: Will default to first of the next month
unless otherwise specified.
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Section F – Producer Agreement and Compensation Disclosure – Required: If left blank and producer
is listed in Section 11 of coversheet, you will receive a letter requesting the completion of this page in
order to be added as the producer.