! Application for Individual Coverage Please list all family members to be covered on this form unless you are enrolling separately.

! Standard Health Questionnaire for Washington State This questionnaire is required* for all individuals submitting applications in Washington State. Please print this form, fill it out, and submit it for each individual (including children) who is applying for insurance at this time.

* The Standard Health Questionnaire for Washington State must be filled out by anyone applying for individual coverage except for the following exceptions. Do not fill out this health questionnaire if any of the following apply to you:

• Exception 1, Medicare: You have Medicare benefits.
  
  
• Exception 2, Newborns or Newly Adopted Children: When a newborn, a child placed for adoption, or a newly adopted child regardless of age is being added to a parent's existing policy, a health questionnaire does not need to be filled out for the child as long as the addition of the child is made within 60 days of birth, placement, or adoption.
  
  
• Exception 3, Exhaustion of COBRA continuation: You are applying for medical insurance because you have used up all the available time on your "COBRA" coverage. In order for this exemption to apply, you must submit your application to the new insurance carrier within 90 days from the date that COBRA coverage ended. Include a letter from your COBRA administrator verifying that you have exhausted your COBRA benefits.
  
  
• Exception 4, Former employer goes out of business: Your former employer, who provided you with health coverage, has gone out of business while you were on "COBRA" coverage, and you are applying for individual coverage with a new insurance carrier within 90 days from the date that coverage ended. Submit verification of your employer going out of business.
  
  
• Exception 5, Relocation: You are applying for coverage with a new carrier because you have moved from one part of Washington State to another, and the insurance carrier that you had does not offer medical coverage where you live now. In order for this exception to apply, you must submit your new application to the new insurance carrier within 90 days from the time that you moved. Include a copy of a utility bill in your name from the prior address and a letter of verification from your prior carrier.
  
  
• Exception 6, Provider cancellation: You are applying for coverage with a new insurance carrier because your doctor or other health care provider has stopped being part of the provider network on your current individual medical plan. In order for this exception to apply:
  
  a) Your doctor or provider must be on the new plan you are applying for;
  b) You must have had some service from that provider during the 12 months before he or she left your current plan, and
  c) You must submit your application to the new insurance carrier within 90 days from the day your provider left your current insurance carrier's network.
  d) This exception does not apply if provider access is lost because your insurance carrier is no longer available.
  
  Include a letter of verification from your provider or carrier.
  
  
• Exception 7, Non-COBRA Continuation: Within the rules described below, you have lost or will be losing your group coverage. In order for this exception to apply, you must be applying for coverage because your employer normally employs fewer than 20 employees (as determined under federal rules known as “COBRA”) and is not, therefore, required to offer you “COBRA” coverage. In addition, for the exception to apply,
  
  a) you must submit your application to the carrier within the period beginning 90 days before the “qualifying event”, and ending 90 days after the qualifying event (as defined under “COBRA");
  b) you had at least 24 months of continuous group coverage immediately prior to the “qualifying event”; and
  c) the effective date of the individual coverage must be on, or within 90 days after, the date of the “qualifying event”.
  
  Under “COBRA”, a “qualifying event” means any of the following events that causes a loss of health coverage: death of the employee; a reduction in hours or a termination of employment (other than by reason of gross misconduct); the divorce or legal separation from the covered employee; the employee becoming entitled to Medicare; a dependent child ceasing to be a dependent child under generally applicable requirements of the health plan; and a bankruptcy filing by an employer from whose employment the employee retired at any time.