Wis. Admin. Code § Ins 3.33 – Individual uniform application for health insurance.

(1) Definitions. For purposes of this section:
1. (a) “Individual major medical health insurance policy” means a comprehensive health care plan offered by an insurer authorized to write individual health or disability insurance for an individual or family. Individual major medical health insurance policies excludes limited-scope dental and vision policies, specified disease policies, short-term medical, hospital indemnity, and other limited-benefit individual insurance products and policies issued by an association plan under a group policy that may be underwritten on an individual basis.
2. (b) “Individual uniform application” means the uniform questions and format for applications that are to be used by insurers offering individual major medical health insurance policies or certificates, including an individual major medical health insurance coverage provided through an association as individual coverage and underwritten on an individual basis and issued to individuals or families, as it appears as form OCI 26-503 in Appendix 1.
(2) Application format and requirements.
1. (a) In accordance with s. 601.41 (10), Stats., insurers offering individual major medical health insurance policies or certificates must use the questions in the same format as in form OCI 26-503 contained in Appendix 1 as the individual uniform application. The contents of the individual uniform application must not vary, except as permitted in sub. (3) (b), from the text or format including bold character, line spacing, the use of boxes around text and must use a type size of at least 10 points.
  Note: A copy of the individual uniform application form OCI 26-503 (c. 06/2010), required in par. (a), may be obtained at no cost from the Office of the Commissioner of Insurance, P.O. Box 7873, Madison, WI 53707-7873, or at the Office’s web address: oci.wi.gov.
2. (b) Insurers offering individual major medical health insurance policies or certificates must implement procedures and policies necessary to implement and utilize the individual uniform application.
3. (c) Insurers offering individual major medical health insurance policies or certificates must treat and accept a paper copy of the individual major medical health insurance application as an original provided the application is received by the insurer within 45 days from the date the application form was originally signed.
(3) Web-based applications.
1. (a) Insurers offering individual major medical health insurance policies or certificates that permit applicants to complete the application through the insurer’s web site may not automatically populate or fill in answers to health questions on the application. An applicant shall answer each question. Insurers may change the order of questions but may not alter the content of any question from the individual uniform application. Insurers must separately request that the applicant respond to questions or information identified in sub. (5). Insurers must send a paper copy of the completed application to the applicant. The paper copy of the completed application must be in the same format as appears in form OCI 26-503 as contained in Appendix 1 and comply with sub. (6).
2. (b) If the insurer requires additional or clarifying information related to a response provided on the individual uniform application, an insurer may ask those questions as part of gathering the information contained in sub. (5) or during a separate contact. Insurers must not gather information unrelated to responses requested on the individual uniform application. If an applicant discloses information that is not requested on the individual uniform application, an insurer must not use that information for purposes of underwriting or making a rescission or reformation decision.
(4) Telephonic applications.
1. (a) Insurers offering individual major medical health insurance policies or certificates may permit applicants to complete the application verbally with an authorized, licensed intermediary or with an employee of the insurer asking the applicant the questions. The intermediary or employee must ask the applicant each question on the uniform individual applicant including each health question. Insurers may change the order of questions but may not alter the content of any question from the individual uniform application. Insurers must separately request that the applicant respond to questions or information identified in sub. (5). Insurers must send a paper copy of the completed application to the applicant. The paper copy of the completed application must be in the same format as appears in form OCI 26-503 as contained in Appendix 1 and comply with sub. (6).
2. (b) If the insurer requires additional or clarifying information related to a response provided on the individual uniform application, an insurer may ask those questions as part of gathering the information contained in sub. (5) or during a separate contact. Insurers must not gather information unrelated to responses requested on the individual uniform application. If an applicant discloses information that is not requested on the individual uniform application, an insurer must not use that information for purposes of underwriting or making a rescission or reformation decision.
(5) Additional requirements.
1. (a) Insurers offering individual major medical health insurance policies or certificates must include a statement on the first page of the policy that the policy is guaranteed renewable except for the reasons stated s. 632.7495 (2), Stats.
2. (b) Insurers must include authorizations, releases, and notices compliant with state and federal law filed with the office as separate forms that will be presented with the individual uniform application but not considered a part of the application.
3. (c) Insurers may file a separate form information or election options for the applicant to select deductible, copayment, and coinsurance levels and elect, if applicable, provider networks. Additionally, insurers may include in the form premium payment options for the applicant to select.
(6) Underwriting. Insurers shall comply with the provisions of s. Ins 3.28, including the requirement to return an accepted application as described in s. Ins 3.28 (5) (d), when underwriting a submitted individual uniform application.
Note: This section first applies to policies issued after July 1, 2010.
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This form is designed for an individual’s initial application for coverage. Please contact the insurer with questions regarding this form.
Instructions: Please complete the entire application for each person for whom coverage is being sought. If a person is currently enrolled in Medicare, this application should not be completed for that enrolled individual. If additional pages are needed to fully complete this application, please attach, sign and date each page.
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Primary Applicant/Insured Information:
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* If you have a Social Security Number.
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* If you have a Social Security Number.
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Within the last Five (5) Years:
1. Infectious and Parasitic Diseases
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2. Blood, Gland, Endocrine, Metabolic and Immune Disorders (other than HIV, ARC, AIDS)
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3. Cancer, Cyst and Tumors
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4. Mental/Nervous/Behavioral Disorders
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5. Brain and Nervous System
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6. Skin Disorders
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7. Eyes, Ears, Nose
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8. Mouth, Throat or Jaw
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9. Heart or Circulatory System
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10. Respiratory System
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11. Digestive System
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12. Urinary System
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13. Male or Female Reproductive Systems
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14. Pregnancy, Birth or Congenital Abnormalities
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15. Muscular or Skeletal System
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16. Miscellaneous
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17. Other Injury, Illness, Treatment or Condition
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18. Tobacco Use
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19. Other Activities
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ONLY complete this section if you need assistance with completing the medical information portion of this Application. Please note that this may require additional time to process your application.
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Signature (or e-signature) of each listed child who has attained the age of 18
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Complete this section if someone assisted you in the completion of this Application
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Individual Uniform Application Form
OCI 26-503 (c. 06/2010)

History

History: CR 10-068: cr. Register December 2010 No. 660, eff. 1-1-11.