UBA Enrollment | United Business Association

Are you an owner or an employee of a small business (less than 50 employees)?

Yes No

Does each person to be enrolled have comprehensive health benefits from an individual or group health insurance policy or an HMO or employer plan providing for essential health benefits?

Yes No

Are you or any person applying for coverage eligible for Medicaid or Medicare?

Yes No

Will the issuance of this short term limited duration coverage result in the Applicant or any Proposed Covered Person being covered with Pan-American Life Insurance Company's short term limited duration plan for more than 18 consecutive months?

If "Yes" then this coverage cannot be issued, you must wait 63 days before you can apply again.

Yes No

Are you or any person applying for coverage eligible for Medicare?

Yes No

Will the issuance of this short term limited duration coverage result in the Applicant or any Proposed Covered Person being covered by a short term limited duration plan for more than 6 months in the last 12-month period from the requested effective date? If "Yes" then this coverage cannot be issued

Yes No

Are you or any person applying for coverage eligible for Medicare?

Yes No

Are you or any person applying for coverage eligible for Medicare?

Yes No

Are you or any person applying for coverage eligible for Medicare?

Yes No

Have/Are you, your spouse, or any person to be insured:

lived in the 50 states of the USA or the District of Columbia for less than the past 12 months?
now pregnant, an expectant parent, in the process of adopting a child or undergoing infertility treatment?
have any other short term medical or major medical expense insurance in force on the requested effective date?

Yes No

Are you or any person applying for coverage eligible for Medicaid or Medicare?

Yes No

Are you or any person applying for coverage eligible for Medicare?

Yes No

Within the past 5 years have you or any person applying for coverage been aware of, had symptoms of, received an abnormal test report for, been diagnosed with, been treated by or received follow-up care with a member of the medical profession, taken medication for any of the following:

Heart or circulatory disorder, heart attack, heart surgery, cauterization or uncontrolled hypertension?
Lung disorder (excluding asthma), emphysema, cystic fibrosis or COPD (chronic obstructive pulmonary disease)?
Crohn's disease or ulcerative colitis?
Stem cell transplant?
Stroke or Transient ischemic attack?
Multiple sclerosis, bipolar disorder, schizophrenia, or eating disorder?
Kidney disorder (excluding kidney stones)?
Liver disorder or Hepatitis c?
Degenerative Arthritis (Rheumatoid Arthritis or Degenerative Joint Disease of knee, hip or disc)?
Muscular dystrophy or systemic lupus?
Cancer or tumor (excluding basal skin cancer)?
Alcohol or drug abuse or other chemical dependency?
Paraplegia or quadriplegia?
Insulin or medication dependent Diabetes?
Blood/Bleeding Disorders including but not limited to: Hemophilia or Leukemia?

Yes No

Have/Are you, your spouse, or any person to be insured:

lived in the 50 states of the USA or the District of Columbia for less than the past 12 months?
now pregnant, an expectant parent, in the process of adopting a child or undergoing infertility treatment?
have any other short term medical or major medical expense insurance in force on the requested effective date?

Yes No

Within the past 5 years have you or any person applying for coverage been aware of, had symptoms of, received an abnormal test report for, been diagnosed with, been treated by or received follow-up care with a member of the medical profession, taken medication for any of the following (excluding Human Immunodeficiency Virus (HIV) testing):

Heart or circulatory disorder, heart attack, heart surgery, cauterization or uncontrolled hypertension?
Lung disorder (excluding asthma), emphysema, cystic fibrosis or COPD (chronic obstructive pulmonary disease)?
Crohn's disease or ulcerative colitis?
Stem cell transplant?
Stroke or Transient ischemic attack?
Multiple sclerosis, bipolar disorder, schizophrenia, or eating disorder?
Kidney disorder (excluding kidney stones)?
Liver disorder or Hepatitis c?
Degenerative Arthritis (Rheumatoid Arthritis or Degenerative Joint Disease of knee, hip or disc)?
Muscular dystrophy or systemic lupus?
Cancer or tumor (excluding basal skin cancer)?
Alcohol or drug abuse or other chemical dependency?
Paraplegia or quadriplegia?
Insulin or medication dependent Diabetes?
Blood/Bleeding Disorders including but not limited to: Hemophilia or Leukemia?

Yes No

Have/Are you, your spouse, or any person to be insured:

lived in the 50 states of the USA or the District of Columbia for less than the past 12 months?
now pregnant, an expectant parent, in the process of adopting a child or undergoing infertility treatment?
have any other short term medical or major medical expense insurance in force on the requested effective date?

Yes No

Within the past 5 years have you or any person applying for coverage been aware of, been diagnosed with, been treated by or received follow-up care with a member of the medical profession, taken medication for any of the following:

Heart or circulatory disorder, heart attack, heart surgery, cauterization or uncontrolled hypertension?
Lung disorder (excluding asthma), emphysema, cystic fibrosis or COPD (chronic obstructive pulmonary disease)?
Crohn's disease or ulcerative colitis?
Stem cell transplant?
Stroke or Transient ischemic attack?
Multiple sclerosis, bipolar disorder, schizophrenia, or eating disorder?
Kidney disorder (excluding kidney stones)?
Liver disorder or Hepatitis c?
Degenerative Arthritis (Rheumatoid Arthritis or Degenerative Joint Disease of knee, hip or disc)?
Muscular dystrophy or systemic lupus?
Cancer or tumor (excluding basal skin cancer)?
Alcohol or drug abuse or other chemical dependency?
Paraplegia or quadriplegia?
Insulin or medication dependent Diabetes?
Blood/Bleeding Disorders including but not limited to: Hemophilia or Leukemia?

Yes No

Within the past 5 years have you or any person applying for coverage been aware of, been diagnosed with, been treated by or received follow-up care with a member of the medical profession, or taken medication for any of the following:

Heart or circulatory disorder, heart attack, heart surgery, cauterization or uncontrolled hypertension?
Lung disorder (excluding asthma), emphysema, cystic fibrosis or COPD (chronic obstructive pulmonary disease)?
Crohn's disease or ulcerative colitis?
Stem cell transplant?
Stroke or Transient ischemic attack?
Multiple sclerosis, bipolar disorder, schizophrenia, or eating disorder?
Kidney disorder (excluding kidney stones)?
Liver disorder or Hepatitis c?
Degenerative Arthritis (Rheumatoid Arthritis or Degenerative Joint Disease of knee, hip or disc)?
Muscular dystrophy or systemic lupus?
Cancer or tumor (excluding basal skin cancer)?
Alcohol or drug abuse or other chemical dependency?
Paraplegia or quadriplegia?
Insulin or medication dependent Diabetes?
Blood/Bleeding Disorders including but not limited to: Hemophilia or Leukemia?

Yes No

Within the past 5 years have you or any person applying for coverage been aware of, been diagnosed with, been treated by or received follow-up care with a member of the medical profession, or taken medication for any of the following:

Heart or circulatory disorder, heart attack, heart surgery, cauterization or uncontrolled hypertension?
Lung disorder (excluding asthma), emphysema, cystic fibrosis or COPD (chronic obstructive pulmonary disease)?
Crohn's disease or ulcerative colitis?
Stem cell transplant?
Stroke or Transient ischemic attack?
Multiple sclerosis, bipolar disorder, schizophrenia, or eating disorder?
Kidney disorder (excluding kidney stones)?
Liver disorder or Hepatitis c?
Degenerative Arthritis (Rheumatoid Arthritis or Degenerative Joint Disease of knee, hip or disc)?
Muscular dystrophy or systemic lupus?
Cancer or tumor (excluding basal skin cancer)?
Alcohol or drug abuse or other chemical dependency?
Paraplegia or quadriplegia?
Insulin or medication dependent Diabetes?
Blood/Bleeding Disorders including but not limited to: Hemophilia or Leukemia?

Yes No

Within the last 5 years, has any person applying for coverage been diagnosed by a member of the medical profession as having acquired immune deficiency syndrome (AIDS) or AIDS-related complex; tested positive for HIV virus?

Yes No

Within the past 5 years have you or any person applying for coverage been aware of, had symptoms of, received an abnormal test report for, been diagnosed with, been treated by or received follow-up care with a member of the medical profession, taken medication for any of the following:

Heart or circulatory disorder, heart attack, heart surgery, cauterization or uncontrolled hypertension?
Lung disorder (excluding asthma), emphysema, cystic fibrosis or COPD (chronic obstructive pulmonary disease)?
Crohn's disease or ulcerative colitis?
Stem cell transplant?
Stroke or Transient ischemic attack?
Multiple sclerosis, bipolar disorder, schizophrenia, or eating disorder?
Kidney disorder (excluding kidney stones)?
Liver disorder or Hepatitis c?
Degenerative Arthritis (Rheumatoid Arthritis or Degenerative Joint Disease of knee, hip or disc)?
Muscular dystrophy or systemic lupus?
Cancer or tumor (excluding basal skin cancer)?
Alcohol or drug abuse or other chemical dependency?
Paraplegia or quadriplegia?
Insulin or medication dependent Diabetes?
Blood/Bleeding Disorders including but not limited to: Hemophilia or Leukemia?

Yes No

Within the past 5 years have you or any person applying for coverage been aware of, had symptoms of, received an abnormal test report for, been diagnosed with, been treated by or received follow-up care with a member of the medical profession, taken medication for any of the following:

Heart or circulatory disorder, heart attack, heart surgery, cauterization or uncontrolled hypertension?
Lung disorder (excluding asthma), emphysema, cystic fibrosis or COPD (chronic obstructive pulmonary disease)?
Crohn's disease or ulcerative colitis?
Stem cell transplant?
Stroke or Transient ischemic attack?
Multiple sclerosis, bipolar disorder, schizophrenia, or eating disorder?
Kidney disorder (excluding kidney stones)?
Liver disorder or Hepatitis c?
Degenerative Arthritis (Rheumatoid Arthritis or Degenerative Joint Disease of knee, hip or disc)?
Muscular dystrophy or systemic lupus?
Cancer or tumor (excluding basal skin cancer)?
Alcohol or drug abuse or other chemical dependency?
Paraplegia or quadriplegia?
Insulin or medication dependent Diabetes?
Blood/Bleeding Disorders including but not limited to: Hemophilia or Leukemia?

Yes No

Within the last 5 years, has any person applying for coverage been diagnosed by a member of the medical profession as having acquired immune deficiency syndrome (AIDS) or AIDS-related complex; tested positive for HIV virus?

Yes No

Within the last 5 years, has any person applying for coverage been diagnosed by a member of the medical profession as having acquired immune deficiency syndrome (AIDS) or AIDS-related complex; tested positive for HIV virus?

Yes No

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