FOR OFFICE USE ONLY
PLAN PLAN CODE ID NUMBER ENROLLMENT FORM Mid Med Endorsement: Please Mail To: Post Office Box 2086 Fort Mill, South Carolina 29716-2086
EFFECTIVE DATE: Employee Name/Owner (First, MI, Last) Social Security Number Gender Date of Birth
Street Address City State Zip
Employer/Group # Job Class Location Date of Hire
Hours Worked Daytime Phone No.
Are you actively at work? ; YES ; NO
; New Enrollment ; Change Plan Selection:
Special Circumstances: Date: Reason: ; Basic ; Enhanced ; Other:
Coverage Level (choose one):
; Employee Only ; Employee Plus Spouse ; Employee Plus Child(ren) ; Family
Monthly Premium: $
Section 125: ; Yes ; No
DEPENDENT INFORMATION Please complete for all covered dependents. No person can be insured under this policy as both a Member and a dependent, or as a dependent of more than one Member. Please complete the following information for each family member you wish to cover.
Relationship First Name M.I. Last Name S.S.# Gender Date of Birth Full Time
Pre-Existing exclusion extends for not more than twelve months without medical care, treatment, or supplies ending after the effective date of coverage or twelve months after the enrollment date, whichever occurs first, under the Group Policy/Certificate. The (12) month period will be reduced based on prior creditable coverage as shown by a Certificate of Prior Creditable Coverage which I must provide. A Pre-existing Condition is any condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the six-month period ending on the enrollment date of coverage for the Covered Person.
This is Important - Please Read
This Election for Coverage Cannot Be Processed Unless The Form Is Signed and Dated.
A new Enrollment Form must be completed for any change such as name change, birth of a child, marriage, adoption of a child, addition of a covered dependent. The new form must be dated, signed and submitted electronically or by email to the Administrator.
I understand that Mid Medical Plan covered persons are covered by group insurance benefits. The group insurance benefits vary depending on the plan selected. These benefits are provided under a group insurance policy underwritten by Continental American Insurance Company and subject to the exclusions, limitations, terms and conditions of coverage as set forth in the insurance certificate which includes, but is not limited to, limitations for pre-existing conditions. This is not
basic health insurance or major medical coverage and is not designated as a substitute for basic health insurance or major medical coverage. This is a limited medical plan that provides for limitations to the coverage and a reduced annual and life time limit. The limitations are disclosed in the policy and certificate which are made available at the time of enrollment.
I acknowledge that I have read the above Notice:
Date of Signature:
； YES, I DO WANT THIS COVERAGE
• I elect coverage for insurance for which I am or may become eligible under the terms of the group policy or policies issued to the policyholder by Continental American Insurance Company.
• All information submitted by me on this form at Continental American Insurance Company’s request, to the best of my knowledge and belief, is true and complete.
• I am applying for coverage with Continental American Insurance Company. I authorize any physician, medical
practitioner, hospital, clinic or medical-related facility or insurance company having information available as to diagnosis, treatment and prognosis regarding any physical, mental, drug or alcohol condition and/or treatment of me or my insured dependents to give/allow the Insurance Company or their legal representatives any and all such information.
• Any information obtained will not be released by the Insurance Company to any person or organization except to
persons or organizations performing business or legal services in connection with my application or a claim for benefits or as may be otherwise lawfully required or as I may further authorize. I understand that this information obtained by the Insurance Company will be used to determine appropriate and accurate medical charges.
• Furthermore, I hereby authorize any physician or practitioner, hospital, or other organization, institution or person, that
has any medical records or knowledge of me or my family, to give to Continental American Insurance Company such information (photocopy of this authorization shall be valid as the original).
• Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty or insurance fraud.
• I also understand that my coverage and that of my dependents, if any, will be subject to the pre-existing condition
limitation and exclusion provision specified in the Master Policy and that this provision has been fully explained to me.
Total Monthly Insurance Amount: $
Date of Signature:
； No, I decline coverage for myself and/or spouse
; I decline coverage because I am covered under another group policy of medical insurance.
; I decline coverage fro my spouse because he/she is covered under another group policy of medical insurance.
; I decline coverage but I do not have another group policy of medical insurance.
(Member/Employee) Declination: ______________________________
Date of signature: _________________________
Agent Signature: __________________________ Date of Signature: ________________________