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Frahm. In that application, Mr. Frahm identified himself as
“Applicant” and Ms. Frahm as “Spouse”. The portion of Mr.
Frahm’s application entitled “Enrollment Information” stated in
pertinent part:
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 A Plan B Plan C[3] (check all that all that apply)
Plan D Plan E Plan F apply) 9 New Enrollment
Plan G Plan H : Self 9 Change
: Spouse 9 Adding/Removing
9 Child(ren) Dependents
* * * * * * *
5. How do you want to pay your premiums?
9 Direct Bill. If so, on what basis? 9 Quarterly 9 Semi-annually
9 Automatic Account Withdrawal. If so, on what basis? (Include a voided check.)
9 Monthly-1st of the month 9 Monthly-5th of the month 9 Quarterly 9 Semi-annually
From: 9 Checking or 9 Savings * * *
6. The amount you are submitting is: $ (One check or money order per application, made
payable to Wellmark, Inc.)
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, explain:
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? : No 9 Yes
7. Qualifying previous coverage Date of termination of previous coverage:
Has this coverage been in effect for 12 consecutive months or more? 9 Yes 9 No
What type of coverage did you have? 9 Employer Group 9 Individual
9 Short Term Major Medical 9 Group Conversion 9 Other (please identify)
Who was your previous insurer? BC/BS If Blue Cross/Blue Shield (BCBS), give details
below.
Name of Contract Holder Ralph Frahm I.D. Number
Group or Employer Name FB Group Name of Blue Cross/Blue Shield Plan
: I want continuous coverage from my previous BCBS program. 9 I do not want continuous
coverage from my previous BCBS
program.
Wellmark approved Mr. Frahm’s Wellmark Plan C application
and issued a health insurance policy to him (Mr. Frahm’s Wellmark
Plan C policy) that covered himself and his spouse Ms. Frahm.
During 2000, Ms. Frahm paid the following premiums totaling
3Mr. Frahm circled “Plan C” as the “Health Care Plan” for
which he was applying.
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Last modified: March 27, 2008