Prior Coverage Information Sample Clauses

Prior Coverage Information for New Groups Does your group have current group medical coverage? ❑ Yes ❑ No If Yes, complete the following information: Name of prior medical carrier: Does your group have current group dental coverage? ❑ Yes ❑ No If Yes, complete the following information: Name of prior dental carrier: The probationary period for your prior carrier was: Date coverage began: Date coverage canceled: Date coverage began: Date coverage canceled: To receive credit for dental waiting periods, please attach a copy of the last billing statement from your prior carrier. Indicate the number of months (next to his or her name) that each employee has been continuously covered (if over 6 months, show as 6+). HSA Plans ❑ HSA H10 ❑ HSA H20 ❑ HSA H30 ❑ HSA H50 ❑ HSA H60 Traditional Plans ❑ Traditional T50 Foundation Plans ❑ Foundation F40 ❑ Foundation F50 ❑ Foundation F60 ❑ Foundation F70 ❑ Foundation F80 Foundation “Plus” Plans ❑ Foundation F45 ❑ Foundation F55 ❑ Foundation F65 ❑ Foundation F75 ❑ Foundation F85 Market Plans ❑ Market M20 ❑ Market M40 ❑ Market M50 ❑ Market M60 ❑ Market M70 ❑ Market M80 Market “Plus” Plans ❑ Market M25 ❑ Market M45 ❑ Market M55 ❑ Market M65 ❑ Market M75 ❑ Market M85 ActiveCare Plans - UW ❑ ActiveCare AU50 ❑ ActiveCare AU70 ActiveCare Plans - Evergreen/Xxxxxxxx Xxxxx ❑ ActiveCare AE50 ❑ ActiveCare AE70 Access PPO Plans ❑ Plan G12 ❑ Plan G22 ❑ Plan G52 ❑ Plan G62 ❑ Plan G72 HMO Plan ❑ Plan G32 ❑ HSA Plan G42 ❑ Plan G60 HSA Plans ❑ HSA Plan G40 ❑ HSA Plan G44 ❑ D10 ❑ D20 ❑ D30 ❑ D40 ❑ Vision V10 ❑ Vision V20 ❑ Vision V30