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1. The Health Care Plan you are 2. This request for 3. This application
applying for is: (PLEASE CIRCLE ONE) coverage is for: is for: (check
Plan I Plan II Plan III[5] Plan IV (check all that all that apply)
Plan V Plan VI Plan VII apply) 9 New Enrollment
Plan VIII Plan IX Plan X 9 Self[6] : Change
Are you applying for the Supplemental : Spouse 9 Adding/Removing
Accident Option? : Yes 9 No 9 Child(ren) Dependents
* * * * * * *
* * * * * * *
5. How do you want to pay your health premiums?
9 Direct Bill. If so, on what basis? 9 Quarterly 9 Semi-annually 9 Annually
: Automatic Account Withdrawal. If so, on what basis? (Include a voided check.)
: Monthly-1st of the month 9 Monthly-5th of the month 9 Quarterly 9 Semi-annually
9 Annually
From: 9 Checking or 9 Savings * * *
6. The amount you are submitting for health insurance is: $179.10 (One check or money order per
application, made payable to Wellmark, Inc.)
The amount you are submitting for life insurance is: $
a. Will your employer be paying any part of the premium for this policy either directly or
through wage adjustments or other means of reimbursement? : No 9 Yes If yes, check one
item below:
9 Applicant is owner of a sole proprietor business 9 Employer is deducting the full
premium 9 Other, please explain
9 Employer has only one eligible employee 9 Employer has been denied the opportunity to
purchase insurance due to low participation
b. Will your premium payments for this coverage be deductible on your federal income tax
return as a trade or business expense other than the special health insurance deduction
available to self-employed persons? 9 No 9 Yes
7. Qualifying previous coverage Date of termination of previous coverage: 01-26-00
Has this coverage been in effect for 12 consecutive months or more? : Yes 9 No
What type of coverage did you have? 9 Employer Group : Individual
9 Short Term Major Medical 9 Group Conversion 9 Other (please identify)
Who was your previous insurer? Golden Rule If Blue Cross/Blue Shield (BCBS), give details
below.
Name of Contract Holder Audrey S. Eyler * * *
Group or Employer Name * * *
Wellmark approved Mr. Eyler’s Wellmark application and
issued a health insurance policy to him (Mr. Eyler’s Wellmark
health policy) that covered himself and his spouse Ms. Eyler.
During 2001, Mr. Eyler paid directly to Wellmark premiums of
$5,066 (health insurance premiums) for Mr. Eyler’s Wellmark
5Mr. Eyler circled “Plan III” as the “Health Care Plan” for
which he was applying.
6Although the box for “Self” in Mr. Eyler’s Wellmark appli-
cation was not checked, the record establishes, and we have
found, that that application was for a health insurance policy
covering both Mr. Eyler and Ms. Eyler.
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Last modified: March 27, 2008