Application submission guidelines healthamerica one
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Application Submission Guidelines HealthAmerica One. New business submission and application completion guidelines. Forms that are needed with every paper application submission:. Required: APPLICATION TRUST AGREEMENT Suggested: MRS FORM (applicants under age 2 or over age 50)

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Application Submission Guidelines HealthAmerica One

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Application Submission GuidelinesHealthAmericaOne

New business submission and application completion guidelines

Forms that are needed with every paper application submission:





  • MRS FORM (applicants under age 2 or over age 50)

  • PAYROLL DEDUCTION FORM (required for all applications with business banking account info submitted)


  • Must pick one desired plan in section A and list requested effective date

  • Applicant must fully complete sections A, B, C, D and sign and date sections E & F ( Be sure to list complete name, address, and phone info for PCP for all applicants)

  • Broker must sign section G or H depending on which version of the application is used and put GA name as agency representing broker

Trust agreement

  • Make sure the applicant signs, dates and lists their address on the trust agreement.

MRS Authorization FORM

  • Most often required for applicants under age 2 or over age 49.

  • 50 and older MUST have seen their PCP or had a physical exam within the last 2 years including whatever tests the doctor deems necessary for that individual’s age.

  • 55 and older MUST have the PE as well, along with the last 5 years of medical records.

  • Having this form signed along with every application will significantly reduce turnaround time in obtaining medical records.

Payroll Deduction Form

  • Must be submitted if the check has a business name on the account

  • If self employed, owner fills out both sections and signs both sections

  • If employer is submitting premium for employee’s insurance the employer and employee will BOTH need to sign the form

  • Must be submitted along with application in order to process.



  • Height/weight must be within standard range

  • No prior claims history if previously covered with Coventry/Health America

  • Must be between age 2 and 49

  • All application medical questions must be answered “no”

  • Case will be sent directly to enrollment to be issued. Can still opt out during the 10 day free look period and receive refund if desired

Auto Enrollment Procedure


  • Applications that are approved by UW with all family members applying approved with no rate increase will automatically be sent to enrollment to be issued.

  • General Agents will still receive email confirmation that the case is being "auto enrolled" with rates, eff date, and plan design noted. NO formal acceptance is required by Health America.

  • The case will be considered "assumed acceptance" if  all family members applying are covered and approved with no rate increase.

  • Remember:  the policy will be issued and automatic bank drafts will be processed unless customer opts out during the 10 day free look.

How to submit new businessapplications

  • Submit your new business applications through the following channels:

  • Submit paper applications. There are three ways to have your applications processed: submit via fax at

    1-866-347-2380, email [email protected] or by mail; Attention: Individual Medical Underwriting Dept P.O. Box 67103 Harrisburg, PA 17106-7103

  • Submit through eHealth, our new electronic tool

  • Updates from underwriting by email on all cases, sent to General Agents to be forwarded to writing agents


Nancy Dudek, Account Executive (WPA & OH) [email protected]

412-577-5409 / 412-849-9150 / 800-735-2202 ext 5409

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