LIST YOURSELF AND ALL ELIGIBLE DEPENDENTS
If you and your spouse are using different last names check applicable box:
Common Law Marriage
Wife Retaining Maiden
ATU SELF FUNDED PPO PLAN (Option 3)
ATU SELF FUNDED PPO PLAN - HIGH DEDUCTIBLE (Option 4)
I certify that the information provided in this Application is true and complete to the best of my knowledge. I understand that any misrepresentation of information may void benefits retroactively to the date benefits began. I authorize use of all my (our) medical records for the Utilization Review, Quality Assurance and Peer Review programs conducted by the Plan or its agents.