Application Agreement and Certification
My signature on this application verifies that I have received the "MedicareBlue SupplementSM Outline of Coverage," the "Guide to Health Insurance for People with Medicare," and a completed copy of this application. My signature also verifies that I have read and understand the "Statements" section that appears above.
My signature verifies that, to the best of my knowledge and belief, I have answered the questions on this application truthfully and completely. I understand that my coverage will not begin until Wellmark Blue Cross and Blue Shield of South Dakota receives and accepts this application and applicable payment and assigns an effective date of coverage. If I answered "No" to the tobacco question on this application, I am eligible for a special tobacco non-user premium. If this status changes, I must notify Wellmark immediately. Wellmark may require me to recertify this status in the future.
My signature further verifies that I understand South Dakota law prohibits knowingly selling more than one Medicare supplement policy to an individual. I certify that if I currently have a Medicare supplement policy in force, I will cancel my current Medicare supplement policy upon notification of acceptance for coverage by Wellmark Blue Cross and Blue Shield of South Dakota. I can request that a Wellmark Blue Cross and Blue Shield of South Dakota representative review my existing policies and advise whether this MedicareBlue policy will duplicate the benefits of my existing health insurance policies by calling (877) 877-8411.
My signature also verifies that I authorize any health care provider to release medical records to Wellmark Blue Cross and Blue Shield of South Dakota when reasonably related to the health insurance coverage for which I have applied. If any law or regulation requires additional authorization for release of medical records, I will give this authorization.
If a condition arises that would have caused an ordinary prudent person to seek medical advice, diagnosis, care or treatment or a condition arose for which medical advice, diagnosis, care or treatment was received or recommended, regardless of the date I signed the application or the date the application was acted upon by Wellmark, I will so inform Wellmark by sending this information in writing to:
Wellmark Blue Cross and Blue Shield of South Dakota
1601 W Madison Street
PO Box 5023, Station 338
Sioux Falls, SD 57117-5023
I understand that premium payments may be made on a calendar month, calendar quarter, semi-annual calendar year or calendar year basis. For example, a monthly premium payment would be for the first day of a month through the last day of such month. A quarterly premium payment would be for any calendar quarterly period, such as January 1 through March 31. A semi-annual premium payment would be for the period of either January 1 through June 30 or July 1 through December 31. An annual premium payment would be for January 1 through December 31 of the applicable year.
In the event I choose to pay my premium on a quarterly, semi-annual, or annual basis and there is a mid-year increase in the amount of premium(s), I will have the following responsibility with regard to an increase in premium(s).
- Quarterly Payments: For quarterly premium payments, I must pay the remaining quarterly premium payments that include the premium increase.
- Semi-annual Payments: For semi-annual premium payments, I must pay a bill for a premium payment that equals the difference between the new semi-annual premium amount and the previously paid first semi-annual premium amount. I also will be required to pay a second semi-annual premium amount that includes the premium increase.
- Annual Payments: For annual premium payments, I must pay a bill for a premium payment that equals the difference between the new annual premium amount and the previously paid annual premium amount.
My signature additionally verifies that I understand and agree that the amount of my periodic premium payment will change as provided in the policy being applied for and from time to time based on changes in my coverage, including but not limited to, changes in benefits, payment obligations (such as deductible, coinsurance and copayments), my age, changes in tobacco user status, or other factors that require adjustments to the total premium. These changes may occur at times other than an annual or other policy renewal.
I further understand and agree that, if I have elected to authorize automatic premium withdrawals from a deposit account, the automatic withdrawal will change periodically to correspond with the applicable premium. My authorization for automatic premium withdrawals shall include authorization for automatic withdrawal of any changed amount unless I call or provide my bank with written notice not less than three (3) business days before a scheduled withdrawal to stop the payment. If I call my bank to stop payment, I may be required to provide a written request within fourteen (14) days after my call. I will be responsible for any fee assessed by my bank for stop-payment orders that I make.
I have read and understand the "Statements" and "Applicant Agreement and Certification" sections on this application. If I am replacing my current coverage, I have completed the "Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage" page of this form. I hereby confirm the authority of Wellmark to make automatic withdrawals from my deposit account as set forth above under "Choose your method of payment," and that this authorization supersedes and replaces any previous authorization given by me with respect to such authority. I understand that any payment will be deposited immediately upon Wellmark's receipt of this application. I understand that Wellmark can change my premium at any time. If I am applying for coverage within 60 days of a premium change with an effective date prior to the premium change, Wellmark will provide notice of the new premium within a reasonable period of time after the enrollment of my application.